Diagnosis Request A Referral Client Physician Client Information Form First Name Sex Male Female Last Name Email D.O.B (MM/DD/YYYY) Phone City Family Doctor Epworth Sleepiness Scale: Please indicate by a number, how likely are you to doze off or fall asleep in the following situations? 0 = never doze 2 = moderate chance of dozing 1 = slight chance of dozing 3 = high chance of dozing Please click correct button 0 1 2 3 Sitting and reading Lying down to rest in the afternoon Watching TV Sitting and Talking to someone Sitting inactive in a public place Sitting quietly after lunch without alcohol As a passenger in a car for an hour without a break In a car while stopped for a few minutes in traffic TOTAL Please check the following signs and symptoms, which are applicable to you: Snoring Witnessed apneas (told that you appear to stop breathing during sleep) Chronic daytime fatigue Difficulty maintaining sleep Feeling tired upon awakening The results of this test may indicate that you are experiencing sleep apnea. At your request this information can be sent to your physician. I hereby confirm that all of the above information is correct and complete, and authorize Pacific Sleep Care to release any part or all of this information to my physician(s). Pacific Sleep Care agrees to keep your information confidential.