Sleep Study Evaluation Form - Shady Grove Adventist Hospital printable pdf download

Sleep Study Evaluation Form - Shady Grove Adventist Hospital

Sleep Study Evaluation Form

Screening questions and neck circumference measurement to establish a need for a sleep study.

1. Have you had a sleep study in the past?

Yes

- If yes; are you currently using CPAP at night?

Yes

A “yes” to question #1 is an Automatic Disqualifier for an outpatient sleep

referral….DO NOT PROCEED

2. Neck circumference

- Male Results: __________

(>17 inches)

Yes

- Female Results: __________ (>16 inches)

Yes

A “yes” to question #2 is an Automatic Qualifier for an outpatient sleep

referral……DO NOT PROCEED

If response to question #1 and/or #2 above is “No” please proceed with the

following screen:

3. Do you have high BP?

Yes

4. Do you fall asleep during the day?

Yes

5. Has anyone ever told you that you snore when sleeping? Yes

Note: If the patient answers yes to two of the above questions the patient is a

candidate for a sleep study. Copy the Screening tool and place in the patients

chart in the daily progress note section. Complete order for sleep Diagnosis and

Treatment. Place this in physician order section of chart for physician signature.

Bring original screen back to the department and place in the folder labeled sleep

study screens.

Sleep Study Evaluation Form - Shady Grove Adventist Hospital