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Sleep Disorder Study Intake Assessment

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Sleep Disorder Study Intake Assessment

The Manitoba government has partnered with Cerebra Health to provide at-home sleep testing to eligible patients on the sleep assessment clinic waitlist (level 2). Patients or their health care provider can complete this intake form to express interest and to help determine their eligibility.

Please note that all patients are screened and must meet at least one eligibility criteria and all patients must be referred and pre-approved before contacting Cerebra. The province will contact you within two weeks of submitting this eform. Please do not contact Cerebra directly.

Screening Criteria

Are you over 18 years of age? Yes No

Are you currently on a waitlist for sleep study testing? Yes No

Do you experience any of the following (please check all that apply): Snoring - Any degree of snoring. Sleep Apnea - Any instances when you stop breathing while sleeping and/or waking up unexpectedly with choking or difficulty catching your breath. Insomnia - Difficulty falling or staying asleep at night. Parasomnia - Any changes to sleeping routine such as sleepwalking, waking up confused, nightmares, bed wetting, or sleep talking. Restless Leg Syndrome - Uncomfortable leg sensations, the urge to move legs, burning, aching, creeping, or crawling sensations that worsen with rest and better with movement. Hypersomnolence - Some degree of feeling tired through the day, waking up feeling tired. Respiratory Failure - Extremely poor breathing on your own. Narcolepsy - Falling asleep suddenly while awake.

Please respond to the following questions regarding the impact of your sleep on daytime activities.

Have you ever had a previous sleep study done? Yes No

Does your sleeping impact and/or impair your quality of life? Yes No

Is it unsafe for you to drive or operate heavy equipment? Yes No

Do you fall asleep unexpectedly (for example, during a conversation, at the movie theatre, in a car)? Yes No

Contact Information

Full name:

Email:

Telephone number:

Regular health care provider (optional):

Acknowledgement

I allow the Diagnostic and Surgical Recovery Task Force team to contact me via email/telephone in response to my submission.
I consent to the disclosure of my personal information that I have submitted for the purposes of determining eligibility for a sleep study.

I understand that my information will be kept confidential in accordance with The Freedom of Information and the Protection of Privacy Act (FIPPA), and will only be used or disclosed for the purposes of determining eligibility for out of province surgery except where authorized or required by FIPPA or another enactment of Manitoba or Canada. By checking this box I declare that I have read, understand and consent to the above statements.

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