August 4,

Sleep Apnea high risk

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Summary: Positive — You are in the highest risk group for obstructive sleep apnea based on your answers. Based on the results of your quiz answers and based on research studies related to this questionnaire, you have a 70{d505be4c556b7ec1c66cb211e58f5c59462cf18006fc380cb71dfa16028c37fb} chance of having obstructive sleep apnea. This condition needs to be addressed as it can cause or worsen many other medical conditions, such as hypertension, diabetes, sexual dysfunction, depression, poor growth, and symptom of ADHD. For a more thorough evaluation, please make an appointment with our office or share this with your primary care physician.

[—- PATIENT: print this referral form, complete the top section, and give to your physician.—- ]

Orlando Sleep Medicine Center
Navin Verma, MD Board Certified in Sleep Medicine
849 Oakwater Circle, Orlando FL, 32806
phone: (407) 704- 8537

Patient Name:___________________________________ Patient Date of Birth:_____________________

Home Phone:______________________________ Work Phone:______________________________

[—- PROVIDER: complete this section, fax to (407) 812-5869—————————— ]

Services requested:
□ Comprehensive sleep medicine consult. Includes polysomnogram & treatment as necessary.
□ Sleep study only, we will send your office a sleep study report.

Special Instructions/Pertinent Medical History:_____________________________________________

Physician Name (printed):_____________________________________________

Physician Phone:________________________________ Fax:________________________________

Physician Signature (required):_____________________________________________

I authorize ORLANDO SLEEP MEDICINE CENTER to perform services on the above patient according to clinical protocols approved by the medical director.


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