Pediatric Sleep Study Worksheet
Page 2 of 3
a. Co-morbid Conditions (recent supporting office notes required):
a. Has the PAP machine been used for >2 months?
b. How many nights a week does the patient use their PAP device?
c. How many hours per night does the patient use their PAP device?
d. Has the patient had a mask refit or adjustment?
e. Has the patient reveived instruction on the proper use and case of their PAP equipment?
Lung disease (cystic fibrosis, uncontrolled
Neuromuscular weakness and impaired
Weekly hypnagogic hallucinations
PAP Compliance for Repeat Studies:
Medications (please list all medications):
a. Has the member had a tonsillectomy and/or adenoidectomy since the prior study?
b. If the member had a tonsillectomy/adenoidectomy, does the member still have
sleep apnea symptoms after the surgery? If so, please list symptoms below
Repeat Study Indication: You may include additional information in section (7)
b. Duration of the Co-morbid Conditions: How long has the patient presented with their co-morbid condition?
< One month. Number of weeks:
> Six months. Number of months:
c. What was the member's apnea-hypopnea index (AHI or number of times there was low airflow during
sleep), lowest SAO2, and highest PCO2 level on the prior sleep test?
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Significant, persistent cardiac arrhythmia
Suspected nocturnal seizures
Documented signs of narcolepsy
Attention Deficit Hyperactivity Disorder (ADHD)