SLEEP DISORDERS CENTER AT Trinitas Regional Medical Center
210 Williamson Street, Elizabeth, New Jersey 07202
Phone: 908-994-8694, Fax: 908-994-8697, Email: Sleep@Trinitas.org


Referral Form For Sleep Study

Patient Name: _____________________________________

Date of Birth: _____________________________________

Telephone: _____________________________________

Cell Number: ___________________________________

Prescribing Physician Name: _____________________________________________________________________________

Telephone: _____________________________________

Fax Number: ___________________________________


Services Requested:

__ One time visit with Diplomate of American Board of Sleep Medicine to assist in Evaluation,
    History and Physical, determination of appropriate sleep study required, and detailed
    recommendations. (History/Physical section not needed. Fax this form to the Sleep Center)

__ Sleep Study Only. Please fill out and fax this H/P form to Sleep Center for review by D'ABSM.


History and Physical:

SLEEP PROBLEMS

__ Witnessed Apneas

__ Tiredness/Fatigue

__ Excessive Daytime Sleepiness

__ Insomnia

__ Snoring

__ Cataplexy

__ Frequent Awakenings

__ Sleep Walking

__ Morning Headaches

 

__ Other: ________________________________________________
 

 MEDICAL CONDITIONS

__ HTN

__ GERD

__ CHF

__ Diabetes

__ Cardiac Arrhythmias

__ COPD/Asthma

__ Stroke/Seizures

 

__ Other: ________________________________________________
 

PHYSICAL EXAM

 

Heart  __ Normal

         __ Abnormal: _______________________________________

Lungs  __ Normal

          __ Abnormal: ______________________________________

Abdomen  __ Normal

              __ Abnormal: ____________________________________

CNS  __ Normal

       __ Abnormal: ________________________________________

HEENT  __ Normal

          __ Abnormal: _______________________________________
 

PRESUMPTIVE DIAGNOSIS

 

 

 

 

__ Sleep Apnea

__ Sleepwalking

__ Narcolepsy

__ Hypersomnia

__ PLMD/Restless Legs

__ Insomnia

__ Nocturnal Seizures

__

__ Other: ________________________________________________
 

TYPE OF STUDY

__ Basic Polysomnogram CPT 95810

__ MSLT CPT 95805****

 

__ CPAP/BIPAP Titration CPT 95811

__ MWT CPT 95805*****

 

__ Split Night CPT 95811

 


Follow up and treatment for sleep related problems e.g. CPAP treatment,
Sleep Hygiene, sleep related medications, etc. will be done by:

__ Vipin Garg, M.D., FCCP, FAASM               __ Prescribing M.D.
 

PHYSICIAN SIGNATURE: ___________________________      DATE: _________________