Sleep Study Referral Pre-Screening Form

Sleep Study Referral Pre-Screening Form — Form Fields

This healthcare template includes 10 fields. Patients complete pre-screening questions for a sleep study referral from their physician. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email (email, required)
• Referring Physician (text, required)
• Hours of Sleep Per Night (Average) (number, required)
• Do you snore loudly? (multiple choice, required) — options: Yes, No, Sometimes
• Have you been told you stop breathing during sleep? (multiple choice, required) — options: Yes, No, Unsure
• Symptoms Experienced (checkboxes, required) — options: Excessive Daytime Sleepiness, Morning Headaches, Difficulty Concentrating, Irritability, Gasping Upon Waking
• Body Mass Index Range (dropdown selection, required) — options: Under 18.5, 18.5-24.9, 25-29.9, 30-39.9, 40 or Above
• Additional symptoms or concerns (long text, optional)