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Collects patient personal and demographic details, contact information, sleep schedule preferences, and physician contact data. Captures history of the sleep problem, relevant medical conditions, social and family history, and structured physical examination sections. Allows selection of study types and special needs, records diagnosis and communication/consent fields, and includes signatures and approval by the ordering physician and designated sleep staff physician to authorize scheduling.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/direct-referral-for-sleep-study-referral-form/168741/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/direct-referral-for-sleep-study-referral-form/168741.png","ImageObject",442,249,{"name":88,"@type":89},"Ezra","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-09-25","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What documents must be submitted with the direct referral for a sleep study?","Question",{"text":108,"@type":109},"Submit the current history and physical for the patient along with the completed form for review.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How does the sleep study get scheduled after approval?",{"text":113,"@type":109},"After the requested sleep study is reviewed and approved by the sleep staff physician, the patient is contacted to schedule the study.",{"name":115,"@type":106,"acceptedAnswer":116},"Which physician information and signatures are required on the form?",{"text":117,"@type":109},"The form requires the requesting physician’s details and includes the ordering physician’s signature with date, plus approval by the facility director or designated sleep staff physician.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},168741,1790022160,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},1099514068035,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","DIRECT REFERRAL FOR SLEEP STUDY\nPlease complete this form and submit for review a current history and physical for the patient.  After review of the information and approval of the requested sleep study by our sleep staff physician, the patient will be contacted to schedule a sleep study.\nPatient Personal Information:\nName:\t\t\t\t\t\t\t\tDate of Birth:\nHome Phone: \t\t\t\t  Cell or Work Phone: (c) \t\t (w)\nDemographics:\nGender: M / F          Age: \t\t\t  Height: \t\t\tWeight:\nSleeping Hours:  From: \t\t\t    To: \t\t\t    □ Night    □ Day   □ Evening\nOccupation:\nPhysician Information:\nRequesting Physician: \t\t\t\t\t  Phone: \t\t   Fax:\nPrimary Care Physician: \t\t\t \t  Phone: \t\t   Fax:\nHistory and Physical Information\nHistory of Sleep Problem:\nMedical Conditions:\n\u000f\nDIRECT REFERRAL FOR SLEEP STUDY cont.\nSocial History & Family History\nPhysical Examination\t\t       \t\tHEENT\nNasopharynx:\nOropharynx:\nJaw/Mouth:\nTongue:\nDentition/Mucosa:\nNeck:\nHeart/Lungs:\nNeurologic Exam:\nReason(s)/Study Types\nType\t\t□Standard\t\t\t□MSLT/MWT\n□CPAP/BiPAP Titration\t\t□Seizure Protocol\n□Split-Night (if indicated)\t\t□Other\nDiagnosis and Special Needs\nDiagnosis:\n□ Obstructive Sleep Apnea \t□ Narcolepsy\t   □ Seizures\n□ PLMD/Restless Legs\t\t□ Hypersomnia      □ ALS\n□ Sleepwalking/RBD\t\t□ Shiftwork\t   □ Insomnia\nSpecial Needs:\n□ Oxygen\t\t□ Assistance Moving\t  □ Wheelchair\n□ Difficulty\t\t□ Medications \t  \t  □ Other\nCommunicating\nOrdering Physician Signature:\t\t\t\t\t\t   Date:\nApproval by facility director/designated sleep staff physician:\n____________________________________________________________  Date:_____________","cbCaigzsucEoHoPK","https://ap.wps.com/l/cbCaigzsucEoHoPK","docx",24774,"English","# Patient Personal Information\n# Physician Information\n# History and Physical Information\n## History of Sleep Problem\n# Social History & Family History\n# Physical Examination\n## Reason(s)/Study Types\n# Diagnosis and Special Needs\n# Communicating","[{\"question\":\"What documents must be submitted with the direct referral for a sleep study?\",\"answer\":\"Submit the current history and physical for the patient along with the completed form for review.\"},{\"question\":\"How does the sleep study get scheduled after approval?\",\"answer\":\"After the requested sleep study is reviewed and approved by the sleep staff physician, the patient is contacted to schedule the study.\"},{\"question\":\"Which physician information and signatures are required on the form?\",\"answer\":\"The form requires the requesting physician’s details and includes the ordering physician’s signature with date, plus approval by the facility director or designated sleep staff physician.\"}]","Direct Referral for Sleep Study - Referral Form | DOCX",1788236370]