Fax Referral Form to:

Sleep Test Referral Ambulatory Home Sleep Test
Patient Information

 Surname	

D.O.B.	

Male      Female	

 Given Names	

 Address	
	
Postcode	

	

Phone	

 Medicare No	

Private health insurance Yes   No	

	
Indications, Symptoms and Health Comorbidities
In order to meet Medicare requirements, patients should have a high probability of moderate to severe OSA using approved assessment tools.  Please tick or write the scores below from the eligible questionnaires (refer over page for details):

Epworth Sleepiness Score ≥ 8	
	
AND	
OSA50 ≥ 5	

	

OR	

	

STOP-BANG ≥ 3

	

OR	

	

BERLIN (tick if positive)

See over for the ESS, OSA50 and STOP-BANG questionnaires or visit www.sleepdiagnostics.com.au/sleepapnoea	

Additional details:	

Telehealth Consultation      Yes   No 	
	
Referring Doctor

 Date	

Provider No.	

 Name	

 Address	

	

Postcode	

 Phone	
	
Fax	

 Email	
	
Signature	

	
Report Preference: Mail  Fax   Email  HealthLink 							
Epworth Sleepiness Questionnaire
How likely are you to dose off or fall asleep in the following situations, in contrast to sitting and reading just feeling tired?  This refers to your recent / current way of life.  Even if you have not done some of these things recently, try to determine how they would affect you.
Circle the response that best describes you:	Never	Slight	Moderate	High	
Sitting and reading	0	1	2	3	
Watching television	0	1	2	3	
Sitting inactive in a public place (e.g. theatre or meeting)	0	1	2	3	
As a passenger in a car for an hour without a break	0	1	2	3	
Lying down to rest in the afternoon when circumstances permit	0	1	2	3	
Sitting and talking to someone	0	1	2	3	
Sitting quietly after lunch without alcohol	0	1	2	3	
In a car as a driver stopped for a few minutes in traffic	0	1	2	3	
		Total =	_______/24	

OSA50
Obesity: Waist circumference (male > 102cm, female > 88cm)	+3		
Snoring: Has your snoring ever bothered other people?	+3		
Apnoeas: Has anyone noticed that you stop breathing during your sleep?	+2		
50: Are you aged 50 years or over?	+2		
TOTAL (5 points or more indicates moderate to high risk)		_______/10	

STOP-BANG
Do you snore loudly? Louder than talking or loud enough to be heard through closed doors?	+1		
Do you often feel tired, fatigued, or sleepy during the daytime?	+1		
Has anyone observed you stop breathing or choking/gasping during sleep?	+1		
Do you have (or are you being treated for) high blood pressure?	+1		
BMI > 35 kg/m2	+1		
Age > 50 years	+1		
Neck circumference > 43 cm  (M)     Neck circumference > 41 cm  (F)	+1		
Gender: Male?	+1		
TOTAL (3 points or more indicates moderate to high risk)		_______/8	
 For the Berlin Questionnaire visit www.sleepdiagnostics.com.au/berlinquestionnaire