Summary: Mild — Your answers suggest that there is a low probability of having obstructive sleep apnea (OSA) or sleep disordered breathing. This is a simple questionnaire that cannot and does not substitute for physician directed medical care and does not mean that sleep disorders have been ruled out in your case. For a more thorough evaluation, please see your primary care physician or make an appointment with our office.
[—- 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:_____________________
Parent/Guardian (if under 18):__________________________________ Relationship:____________________
Home Phone:______________________________ Work Phone:______________________________
[—- PROVIDER: complete this section, fax to 407-812-5869 —————————— ]
□ 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):_____________________________________________