J6166 Ycasc Referral Form - Toronto Sleep Clinics Ontario Sleep
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1REFERRAL FORM
227 Victoria St., Lower Level 2, Toronto, Ontario M5B 1T8
Phone: (416) 703-0505
Fax: (416) 703-0507
Personal Information:
Name:
DOB:_________________OHIP#:____________________________________
Contact #:
Age: _______ Gender: ❒
❒
Height:_______Weight:________
Male
Female
Referring Physician:
Name:
Address:
Phone:
Fax:
Billing #:
REASON FOR REFERRAL: (please circle all relevant)
COMMON NIGHTTIME SYMPTOMS
COMMON DAYTIME SYMPTOMS
• snoring, breathing problems, sleep apnea
• difficulty waking up
• bed wetting (enuresis)
• excessive sleepiness
• teeth grinding (bruxism)
• tiredness
• sleep walking (somnambulism)
• irritability
• nightmares, night terrors
• hyperactivity
• RLS/PLMS
• behavioral problems in school
• Sweating
• declining school performance
• Seizure disorder
• other ________________________
• Insomnia
History & Medical Information:
Referring Physician Signature:
Date:
9/2006
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Parent category: Medical