Patient information
Referrer
Question
Complaint
Medical history
Differential diagnosis / Diagnosis
Has there been consultation/diagnostics/treatment elsewhere for this?
If yes, where?
What were the findings?
Was the case discussed with a practitioner at Kempenhaeghe?
If yes, with whom?
Does the patient have an intellectual disability?

 

If the referral concerns sleeplessness/insomnia:
Where did CGT-i take place:
What sleep diagnosis was made:
Which medical comorbidity is involved:
Which psychiatric diagnoses have been established: Where does current treatment take place:
(for acceptancy policy see previously on this page)

Note: Please send attachments, such as results of previous diagnostic examinations and correspondence, listing the patient’s information, to:

Kempenhaeghe
attn. secretariaat polikliniek Center for Sleep Medicine
Postbus 61
5590 AB Heeze

Of:

Kempenhaeghe
attn. secretariaat polikliniek Center for Sleep Medicine
Postbus 250
4900 AG OOSTERHOUT