HOME SLEEP STUDY REFERRAL FORM

Suite 18, Level 1, San Clinic Parkway, 172, Fox Valley Road, Wahroonga, NSW 2076
02 9487 8373
02 9475 0435
info@sydneyrespiratoryspecialist.com.au	

Patenit Details

NAME:           Click or tap here to enter text.	

DOB: 	

MOBILE NO:  Click or tap here to enter text.	

MEDICARE NO:  	

ADDRESS:    	

	

REFERRING DOCTOR:

NAME OF DR	
Click or tap here to enter text.	
PROVIDER NO: 

SLEEP STUDY REQUEST:

☐	
Fast-tracked bulk billed sleep study according to Medicare guidelines (Please tick the sleep study questionnaires to check Medicare eligibility)

☐	
Review with a Sleep Specialists (Charges apply) to assess the suitability for a bulked-bill sleep study	

FOLLOW UP ARRANGEMENTS:

☐	
Once the sleep study is performed, if sleep Apnoea is diagnosed, would you like us to organize a consultation with one of our sleep specialists to discuss the results and treatment plans with your patient, and use this form as a referral? 	
☐	
Would you (referring doctor) like to follow the patient yourself?	

Patients who have an Epworth sleepiness score of 8 together with either a STOP-Bang score of 3 or more/OSA50 score of 5 or more are considered high risk of sleep apnoea and will qualify for a fast-tracked-bulk-billed sleep study without requiring seeing a sleep physician. 

Please fill the Questionnaires below:

Please fill the below questionnaires to assess the eligibility of your patient to obtain a fast tracked bulk billed home sleep study
	
EPWORTH SLEEPINESS SCLAE	

How likely are you to doze off or fall a sleep in the following situations? Please circle the appropriate number

0 No Chance            |  1 Slight Chance                     |  2 Moderate Chance                     |   3 High Chance

Sitting and reading	
  0	
   1	
  2	
3	

Watching television	
  0	
   1	
  2	
3	

Sitting inactive, in a public space	
  0	
   1	
  2	
3	

Lying down to rest in the afternoon when circumstances occur	
  0	
   1	
  2	
3	

Sitting and talking to someone	
  0	
   1	
  2	
3	

Sitting quietly after lunch without alcohol	
  0	
   1	
  2	
3	

As a passenger in a car for an hour without a break	
  0	
   1	
  2	
3	

In a car, while stopped for a few minutes in traffic	
  0	
   1	
  2	
3	

TOTAL SCORE

                      / 24 pts	

‘STOPE BANG’ QUESTIONNAIRE

For a Medically subsidised sleep study a patient must score 4 or more Please circle the appropriate box

YES	
NO	

Do you snore loudly?	
☐	
☐	

Do you often feel tired?	
☐	
☐	

Has anyone observed you stop breathing or chocking/gasping during your sleep?	
☐	
☐	

Do you have or are you being treated for high blood pressure?	
☐	
☐	

Is your body mass index more than 35kg/m2 ?	
☐	
☐	

Are you aged older than 50?	
☐	
☐	

Is your gender male?	
☐	
☐	

For men, is your neck size 17 inches/ 43 cm or larger (measured around Adams apple)? For Women, is your neck size 16 inches/ 41 cm or larger?	
☐	
☐	

TOTAL SCORE

    / 8 pts	

OSA 50 SCREENING QUESTIONNAIRE

Please add up to the final score

	
IF Yes Score Below	

Obesity	
Waist circumferences – Male> 102 cm | Female > 88cm	
3	

Snoring	
Has you’re snoring ever bothered other people?	
3	

Apnoeas	
Has anyone noticed that you stop breathing during your sleep?	
2	

50	
Are you aged 50 years and over?	
2	

TOTAL SCORE

                  / 10 pts	

Thank you for your referral to the Sydney Respiratory Specialist Clinic