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Malvern
Sleep Clinic
416-282-9119
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Please Complete All Sections in Full
Patient name:
Sex:
Male
Female
D.O.B. (dd/mm/yy)
HCN
Version Code
Address:
Postal Code
Home#
Bus.#
Family Physician
ADULT SERVICES:
Consultation with Sleep Studies as required
Sleep Study only
Consult Only
CPAP follow up
Attention to
Dr. D. Ross
Dr. M. Narayan Singh
Dr. J.S. Anthony
Dr. A. Chelvanathan
PEDIATRIC SERVICE:
Consultation with Dr. S. Bola and Sleep Studies as required
Sleep Study only (must fill out past medical history in full, including all “no” responses, where appropriate, if sleep study only)
REASON FOR REFERRAL
Snoring
Non-Restorative Sleep
Adeonoid/Tonsils Hypertrophied
Apnea
Morning Headache
Obesity
Insomnia
Difficulties with attention/focus
CPAP follow up
Parasomnia
Fibromyalgia / Chronic Pain
Nocturnal Seizures
Shift Work Problems
Narcolepsy
Restless Legs/Limb movements
Morningh Headache
MSLT/MWT
Post surgical follow up
Oral Appliance Follow up
Hypersomnolence/fatigue
Other - please describe:
PAST MEDICAL HISTORY:
Asthma
Y
N
Heart Failure
Y
N
Dementia
Y
N
ADHD
Y
N
COPD
Y
N
Cardiomyopathy
Y
N
Bruxism
Y
N
Pulmonary Hypertension
Y
N
Arrhythmia
Y
N
Alcoholism
Y
N
GERD
Y
N
Sickle Cell Disease
Y
N
Diabetes
Y
N
Depression
Y
N
Autism
Y
N
Craniofacial Abnormalities
Y
N
Hypertension
Y
N
Anxiety
Y
N
Seizures
Y
N
Prader-Willi Syndrome
Y
N
CAD
Y
N
Stroke
Y
N
Trisomy
Y
N
Achondroplasia
Y
N
Angina
Y
N
Parkinson’s Disease
Y
N
Congenital Heart Disease
Y
N
Other:
Current Medication:
Has the patient ever had a sleep study in the past?
Yes
No
REFERRING PHYSICIAN
Billing#
Name:
Mailing address:
Postal Code:
Phone#:
Fax #:
Date:
Signature:
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