Sleep Disorders Center Polysomnogram Request Form
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1If patient has
Before the Sleep
If patient has Patient
st
Patient 1
,
Study is scheduled
st
1
, Medicaid,
Medicaid,
we must have:
TriCare, or Visa, we
TriCare, or Viva,
- Referral
will need the referral
we will need the
- Clinic notes
from the PCP with a
referral from the
- Patient history
valid EPSDT
PCP with a valid
- Demographic
screening date.
SLEEP DISORDERS CENTER
EPSDT screening
sheet.
POLYSOMNOGRAM REQUEST FORM
date.
1600 Seventh Avenue South
Birmingham, Alabama 35233
Telephone (205) 939-9386 Fax (205) 558-2466
In order to better serve our patients, we ask that you provide the following information from your history
and physical examination of this child. A copy of your office notes may contain all the needed information.
Please fax it to the Sleep Disorders Center as soon as possible. *A physician’s signature is required.
NAME: _____________________________________
DATE OF BIRTH: ______________________
SLEEP STUDY: __________________________
MR#: _____________________________________
CURRENT COMPLAINT: _______________________________________________________________
CURRENT MEDICATIONS: _____________________________________________________________
HISTORY:
________________________________________________________________________
________________________________________________________________________
SLEEP HISTORY:
BED TIME: __________ RISE TIME: ________ EXCESSIVE DAYTIME SLEEPINESS: __________
SNORING: _____ GASPING/CHOKING: _______ INITIATING AND MAINTAINING SLEEP:______
OTHER CONCERNS: ___________________________________________________________________
PHYSICAL REVIEW:
HEIGHT: ____________________ WEIGHT: ____________________ NOSE: _____________________
PULMONARY: ________________________________________________________________________
THROAT: ________________________
NECK: ___________________________________________
ABDOMEN: ___________________________________________________________________________
CARDIOVASCULAR: _______________________ NEUROLOGICAL: _________________________
Referring Physician Name: ______________________________________________________________
Mailing Address: _______________________________________________________________________
Telephone: _________________________________________ Fax: _____________________________
***PHYSICIAN SIGNATURE***
Physician Signature: ______________________________________________ Date:__________________
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