Refer Patient to: Children’s Lung, Asthma & Sleep Specialists (THE CHILDREN’S SLEEP LAB)
AKINYEMI AJAYI, MD, FCCP, FAASM, D, ABSM
PHONE: 407-898-2767 - FAX: 407-898-9443 TOLL FREE 866-383-0556 - TOLL FREE FAX 877-898-9443
Patient Name: / M or F / DOB: / Social Security #:Guarantor Name: / M or F / DOB: / Social Security #:
Address: / City, State, Zip
Home Phone: / Cell Phone:
PCP (if not referring MD): / Phone:
Please check if the referring office would like to be notified when appointment is set: Yes No
Insurance Company: / Insurance ID:
Sleep Study Referral
Please circle:
1. Obstructive sleep apnea syndrome
2. Central sleep apnea syndrome
3. Attention deficit hyperactivity disorder or attention deficit disorder with suspected obstructive sleep apnea syndrome
4. Narcolepsy
5. Hypersomnia
6. Sleep parasomnias (Sleep terrors, confusional arousals, sleep walking)
7. Insomnia Circadian rhythm disorder (Delayed/Advanced sleep phase syndrome)
8. Neurobehavioral / Sleep Psychologist Evaluation
9. Other Diagnosis______-
Please circle type of service requested:
1. Sleep clinic consultation
2. Sleep clinic consultation and diagnostic sleep polysomnography
a. Diagnostic sleep polysomnography
3. Diagnostic sleep polysomnography with CPAP titration
4. Multiple sleep latency test
Please indicate your preference for further referrals (if needed):
· We (PCP/Pediatrician) will refer all patients for further treatment:
· We would like you (Sleep Lab) to refer patients for further treatment:
· Please use the following physician for treatment: / ______
ENT: / Psychologist: / Cardiologist: / Neurologist: / G.I.:
RSV Prophylaxis – synagis referral
Gestational Age (GA) at birth:
Birth Weight:
Primary Diagnosis:
Extreme immaturity (gestation of <29 completed weeks.)
Respiratory distress syndrome
Chronic Respiratory disease arising in the neonatal Period
Other Conditions:
Current Medical Information
Current Weight: / Date Weighed:
Date of first injection given:
Allergies:
General Indications: Based on AAP guidelines from July 2014
· GA< 29 weeks and <1 year of age at start of RSV season (9/1/2014) (Born AFTER September 1st 2014)
· GA >29 weeks with chronic lung disease of prematurity and >21% O2 for > 28 days.
· GA<29 weeks and <2 years of age with continued O2 therapy, chronic corticosteroid, diuretic therapy within 6 months of start of RSV season (3/1/2014)
· GA>32 weeks with hemodynamically significant heart disease defined as (use of > 21% O2 for > 28 days), pulmonary abnormality or neuromuscular disease that impairs the ability to clear secretions from the upper airways.
/ Pulmonary Function Test Referral
Please circle:
1. Asthma / Reactive Airway Disease
2. Wheezing
3. Ongoing assessment of patient on inhaled steroids/bronchodilators
4. Cough
5. Pneumonia
6. Shortness of breath/Dyspnea
7. Obesity
8. Frequent colds
9. Cancer/Chemotherapy patient
10. Suspected interstitial disease
11. Suspected restricted lung disease
12. Sickle cell disease
13. Other Diagnosis:______
Please circle type of service requested:
1. Complete pulmonary function tests include option 2,3,4 and 5
2. Spirometry pre bronchodilator pre/post bronchodilators
3. CO Diffusing capacity
4. Airway resistance measurements
5. Lung volumes by Body Plethysmography , By gas dilution
Allergy testing/Allergy immunotherapy
Please Select: Skin testing or Immunotherapy (No Foods, Fruits, Nuts & Seafood)
Trees / Grasses / Molds
Pediatric Foods and Nuts / Fruits and Nuts / Seafood Panel
Indoor Allergens / Pets and Insects
New pulmonary consult referral
Reason for referral:
Sleep psychologist services
Psychological Consultation: (please select from below):
o Hyperactivity
o Anxiety
o Attention Deficit Hyperactivity Disorder (ADHD):
o Combined type
o Inattentive type
o Hyperactive type
o Insomnia
o Narcolepsy/Excessive Sleepiness
o Bedtime Resistance
o Night Awakenings
o Poor Sleep Habits
o Parenting Strategies / Limit Setting
Revised 11-2015