Sleep Laboratory Referral Form

Sleep Questionnaire

Please fill out the referral form below:

We are a Southern Cross Affiliated Provider

Sleep & Breathing (NZ) Limited
Ascot Office Park, Level 3, Building B
93-95 Ascot Avenue, Greenlane East
P O Box 109-409, Newmarket
Auckland 1149
Fax 09 638 6022
Telephone 09 638 5255
Email referrals@nzrsi.health.nz
 
 

PATIENT'S DETAILS

REFERRAL REQUESTED





Note: Patients with tonsillar hypertrophy, anatomical nasal obstruction, or mucosal nasal obstruction (not responding to medical therapy) should first be seen by an Otolaryngologist.

TYPE OF INVESTIGATION

(Please hover your mouse over a test to see an explanation of that test)










CLINICAL DETAILS

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REFERRING DOCTOR

Fields marked * are required

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Phone Southern Cross on 0800 800 181

Screening Respiratory Study

Five channel study (airflow, snore, oximetry, body position, actigraphy).

Used when there is a high probability of sleep apnoea*, no co-morbidities, no important ENT abnormalities. Can be used to exclude important sleep apnoea in patients with heavy snoring and to screen for sleep apnoea in patients with severe hypertension or unstable diabetes who snore but are not sleepy.

* High probability of Sleep Apnoea is characterised by loud habitual snoring, observed apnoeas, and an Epworth Score of greater than 15/24.

Complex Respiratory Study

Eight channel study (airflow, snore, chest and abdominal movement, ECG, EMG, oximetry, body position, and pulse pressure).

Used when there is a moderate to high probability of sleep apnoea*. No co-morbidities, no important ENT abnormalities.

* High probability of Sleep Apnoea is characterised by loud habitual snoring, observed apnoeas, and an Epworth Score of greater than 15/24.

Diagnostic Polysomnography (PSG)

16 channel study (airflow, snore, chest and abdominal movement, ECG, EMG, EEG, EOG, oximetry, body position, pulse pressure, leg EMG, video monitoring).

Used when there is a low, medium, or high probability of sleep apnoea* in conjunction with co-morbidities, or suspicion of OSA and a second sleep disorder.

* High probability of Sleep Apnoea is characterised by loud habitual snoring, observed apnoeas, and an Epworth Score of greater than 15/24.

Split Night (PSG)

16 channel study (airflow, snore, chest and abdominal movement, ECG, EMG, EEG, EOG, oximetry, body position, pulse pressure, leg EMG, video monitoring).

Used when there is a low, medium, or high probability of sleep apnoea in conjunction with co-morbidities, or suspicion of OSA and a second sleep disorder. In instances where OSA is present, CPAP is applied in the second half of the study.

CPAP Pressure Setting Study

(In Lab): 14 channel study following Sleep Study showing Sleep Apnoea (airflow, snore, chest and abdominal movement, ECG, EMG, EEG, EOG, oximetry, body position, pulse pressure, leg EMG, video monitoring), and CPAP pressure titration by a trained sleep technician.

(In Home): Auto adjusting flow sensing device used for 1 week.

Note: This test is not currently being reimbursed by Southern Cross Health Insurance

MSLT with prior PSG

14 channel PSG followed by five naps during the following day.

Used when there is suspicion of Narcolepsy/Cataplexy syndrome, evaluation of unexplained daytime somnolence, and for legal cases. Usually requires specialist opinion prior to test.

MWT with prior PSG

14 channel PSG followed by five naps during the following day.

Used for clearance for driving or flying after a therapeutic intervention. Always requires a specialist opinion.

Actigraphy / Sleep Diary

Movement sensor and sleep diary, records for 30 days.

Used to evaluate non-responsive insomnia and circadian rhythm problems.

Note: This test is not currently being reimbursed by Southern Cross Health Insurance

Infrared Video Monitoring

Test undertaken in patient's own home looking for parasomnias.

Note: This test is not currently being reimbursed by Southern Cross Health Insurance

Click to calculate Epworth Sleepiness Score.