Peninsula Sleep Laboratory

Peninsula Sleep Laboratory Questionnaire

DO YOU SUFFER FROM ANY OF THE FOLLOWING?

Please tick appropriate box:

Stop breathing during sleep
Snoring
Daytime Sleepiness
Diagnosed Narcolepsy
Insomnia
Hypertension (high blood pressure)
Heart Disease
Nasal Problems - Sneezing, Blocked nose, Runny nose, Other
Falling asleep at inappropriate times - Waiting at red lights, meetings, etc...
Wake with a dry mouth
Gastro-oesophageal Reflux (Heartburn)
Waking Choking
Need to go to toilet during the night
Impotence / Decreased libido (sex drive)
Poor memory / concentration
Restless legs
Leg Cramps
Morning headache

Your score is 4 or below.

A score of 5 or more suggests that a sleep study may be indicated. This should be discussed with your Doctor, who may alternatively choose to refer you to a Sleep Physician for further assessment.
Your score is 5 or above.

Contact your Doctor for further advice in relation to your symptoms as a sleep study is recommended.

Sleep study appointments

Sleep studies and other tests are by are by referral only. If you have a referral and need to schedule an appointment or would like further information please call the receptionist. If you need to change or cancel your appointment it would be appreciated if you would call the receptionist.

Referrals

Written referrals are required for all types of studies. For CPAP and other specific tests all patients must be seen and referred by a Sleep / Respiratory Physician. For diagnostic studies patients can be referred by any registered doctor or dentist (as per HIC rules). Referrals from general practitioners usually last 12 months from 1st date of service and referral from specialists last 3 months from 1st date of service. Referrals over 12 months old can not be accepted.