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Thank you for requesting Sequoia's Sleep Disorder Center for your sleep testing needs. Please fill in the necessary information so we may swiftly expedite your request.

Date: Patient's name:

Ordering physician:

Phone: Fax:

Indications:

witnessed apnea snoring nocturnal choking fitful sleep

excessive sleepiness chronic fatigue difficulty initiating/maintaining sleep

post UPPP elongated palate nasal obstruction swollen turbinates

erectile dysfunction obesity hypertension p.m.alcohol

Pertinent medical history:

Tests requested:

Apnea evaluation with NCPAP titration if indicated  without NCPAP titration

Apnea evaluation-ambulatory monitoring      Home oximetry monitoring

Maintanence of Wakefulness Multiple Sleep Latency Testing

Esophogeal pH monitoring    Nocturnal penile tumescence

Follow up: will be done by me Please schedule consultation with

Dr: Votteri Pavy Wilson Tene Lim