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Get Georgetown University Hospital Sleep Disorders Center Physician’s Order/Direct Referral Sheet

ICIAN: Address: Phone: Zip: Fax: PATIENT INFORMATION: Patient: DOB: Address: City/State: Home#: Work#: Height: Weight: Gender: M / F Occupation: SSN: Other: HISTORY & PHYSICAL INFORMATION: *Please complete this section or attach a current History & Physical to this form. Witnessed apnea History of prior documented sleep apnea Snoring Sleep Paralysis Falls asleep during the day Hypertension Falls asleep while driving Morning headaches Daytime fatigue History of prior upper airwa.

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