Sleep study referral letter

Fill in the fields and click “Create referral letter (PDF)” at the bottom. The PDF is generated in your browser; nothing is sent to our server.

Required fields are marked with *.

Referring physician

Name *

RIZIV/INAMI number *Format 1-23456-78-901

Practice address

Telephone

Patient

Surname and first name *

Date of birth *

Sex

Male Female Other / not stated

National register number (optional)In Consult you look up the patient by national register number.

Requested study *

Polygraphy Polysomnography Sleep physician decides

Preferred site

Urgency

Normal Increased (professional driver, recent accident, pregnancy, pre-operative)

Urgency details

Clinical information

Height (cm)

Weight (kg)

BMI—

Neck circumference (cm)

How likely is the patient to doze off or fall asleep in the following situations? 0 = never, 1 = slight chance, 2 = moderate chance, 3 = high chance.

	0	1	2	3
Sitting and reading
Watching television
Sitting inactive in a public place (theatre, meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

ESS total: —

One point per yes. The items BMI, age, neck circumference and sex are derived from the data above, but you can override them.

STOP-BANG total: 0 / 8

Comorbidity

Current medication

Previous sleep study or CPAP?

No Yes

Details (where, when, result)

Clinical question *

Decision aid

Fill in the STOP-BANG items for a suggestion.

The sleep physician reviews every request and may change the type of study.