Sleep Apnea Referral Questionnaire

Patient's Full Name:

DOB:

Patients Phone Number:

Insurance Name:

Insurance Medical ID number:

Group/Policy #

Patients Address City State Zipcode:

Date

Provider Name:

Clinic/Facility:

1. Reason for Referral

Suspected Obstructive Sleep Apnea (OSA) Evaluation of excessive daytime sleepiness Snoring and witnessed apneic events Re-evaluation of previously diagnosed sleep apnea Other

If Other (specify):

2. Sleep History (Provider-Reported or Based on Patient Report)

Loud, habitual snoring Witnessed pauses in breathing or gasping/choking during sleep Excessive daytime sleepiness or fatigue Morning headaches Unrefreshing sleep Dry mouth or sore throat upon awakening Difficulty concentrating or memory issues Restless or fragmented sleep

Duration of symptoms:

3. Relevant Medical History

Hypertension Obesity (BMI: _______) Diabetes Mellitus Coronary artery disease Heart failure Stroke or TIA Atrial fibrillation or other arrhythmia COPD or asthma Hypothyroidism Depression or anxiety Use of alcohol or sedatives

BMI:

Other relevant conditions:

4. Physical Examination Findings

Height:

Weight:

BMI:

Neck circumference:

Blood Pressure:

Crowded oropharynx (high Mallampati score) Enlarged tonsils or uvula Nasal obstruction or septal deviation Retrognathia or small jaw Enlarged tongue

5. STOP-Bang Screening (Provider Use)

STOP-Bang Item

Snoring loudly

Yes No

Tired during daytime

Yes No

Observed apnea

Yes No

High blood pressure

Yes No

BMI > 35

Yes No

Age > 50

Yes No

Neck circumference > 16 in (F) / 17 in (M)

Yes No

Male gender

Yes No

STOP-Bang Score:

Low Risk Intermediate High Risk

6. Additional Notes

7. Referral Request

Diagnostic sleep study consult (home sleep test) TMD Botox

Preferred method of follow-up:

Fax EMR Phone Email

Provider Signature:

Date: