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Home Sleep Testing Order

Complete General Information form.
Complete our Epworth Sleepiness Scale form.
Complete our Medical Necessity Determination form.
Choose method of payment. Payment by insurance, credit, debit, or PayPal. For insurance, we accept Medicare or any insurance in DE & MD, except MD Medicaid.

Step 1 of 4

25%

Where is the Patient Located?*
- New Castle County, DE – ApneaLink ((involves picking up and dropping the test machine back))
- Located elsewhere – WatchPAT ONE Sleep Test
Name*
Gender*
- Male
- Female
Height (Feet)*
Height (Inches)*
Weight*
Email*
Phone*
Primary Care Provider
Primary Care Phone
Primary Care Provider Address
Street Address City State ZIP Code

Epworth Sleepiness Scale

This questionnaire was developed to determine the level of daytime sleepiness in individuals. It has become one of the most frequently used methods for determing a person’s average level of daytime sleepiness.

Please rate how likely you are to doze or fall asleep in the following situations by selecting the response that best applies. If you have not done some of these activities recently, select what would most likely happen if you were in that situation.
Sitting and reading
Please enter a number from 0 to 3.
Watching television
Please enter a number from 0 to 3.
Sitting inactive in a public place (eg. a theater or a meeting)
Please enter a number from 0 to 3.
As a passenger in a car for an hour without a break
Please enter a number from 0 to 3.
Lying down to rest in the afternoon when circumstances permit
Please enter a number from 0 to 3.
Sitting and talking with someone
Please enter a number from 0 to 3.
Sitting quietly after a lunch without alchohol
Please enter a number from 0 to 3.
In a car, while stopped for a few minutes in traffic
Please enter a number from 0 to 3.
Epworth Sleepiness Score

Medical Necessity Determination
Do you snore?*
- Yes
- No
Is your shirt collar size 17 inches or larger?*
- Yes
- No
Is your shirt collar size 16 inches or larger?*
- Yes
- No
Do you have sleepiness in waking hours?*
- Yes
- No
Do you have a history of (select all that apply):*
- Atrial Fib?
- Heart Attack?
- Heart Failure?
- Hypertension?
- Insomina?
- Stroke?
- None of the above
Are you on oxygen supplementation?*
- Yes
- No
Has anyone observed you stop breathing, choking or Gasping during your sleep?*
- Yes
- No

Payment
We will call you regarding payment and further details.

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