Please Note: In order for AJCH to efficiently manage your referral, this form must be fully completed and along with all requested documentation. All referrals will be dealt with between the hours of 09:00 -14:00 Sun- Thurs.

Referring Physician Details
Patient Details
Male Female
Parent/Guardian Details
Health Insurance Information

Please provide a copy of insurance card, front and rear, together with progress notes for authorization purposes

+

Instruction For Study
Baseline Sleep Study CPAP/BIPAP Titration Split Night Study Overnight Oximetry
Would you like the patient to be seen at the Paediatric Sleep Clinic prior to the sleep study?
Yes No
Sleep History
Does, Or Has, The Patient:
Snore excessively more than 3 nights a week?

Yes

No

Been observed to stop breathing or have pauses in breathing during sleep?

Yes

No

Awaken with gasping, choking, dry mouth or throat?

Yes

No

Tend to be a mouth breather?

Yes

No

Occasionally wets the bed (for children 3 and older)?

Yes

No

Feel sleepy or fatigued during the day?

Yes

No

Have poor school performance?

Yes

No

Have hyperactivity or is inattentive?

Yes

No

Suffers from morning headaches?

Yes

No

Experience a restless sensation in arms or legs during sleep or in the evening?

Yes

No

Been told that they make kicking movements during sleep:

Yes

No

Have difficulty falling asleep at the beginning of the night?

Yes

No

Have difficulty staying awake during the day?

Yes

No

Have sudden loss of strength in arms or legs while awake? (Induced by strong emotion)

Yes

No

Had a previous sleep study?

Yes

No

If so, when and where?

Yes

No

How long does it typically take the patient to fall asleep?

Yes

No

PM

AM

Medical History
Asthma
Enlarge tonsils
Deviated septum
Gastroesophogeal Reflux
Allergies
Enlarged adenoids
Nasal obstruction
Craniofacial Malformation
Obesity
Previous T&A?
Enlarged Tongue
Seizures
Cardiac problems
Nasal polyps
Diabetes
Other Medical History/Allergies:

I authorize lab to perform sleep studies on above patient according to their protocols, including urgent initiation of o2 & cpap

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)