Fax Referral Form to:
Orana Mall Pharmacy, Dubbo
Fax Number- 6884 6284
		
Sleep Test Referral     Ambulatory Home Sleep Test
				
		Patient Information			
		Surname	  Patient Demographics.Surname	 D.O.B.	  Patient Demographics.DOB	Gender	  Patient Demographics.Gender			
		Given Names	  Patient Demographics.First Name			
		Address	  Patient Demographics.Address, Patient Demographics.Suburb, Patient Demographics.Postcode			
		Phone	 (h) Patient Demographics.Phone (Home)             (m) Patient Demographics.Phone (Mobile)			
		Medicare No	  Patient Demographics.Medicare Number	Private health insurance	 Patient Demographics.Health Fund Name			

		
		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):
Epworth Sleepiness Score ≥ 8	
	
AND	
OSA50 ≥ 5	

	

OR	

	

STOP-BANG ≥ 4	

	

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	 Miscellaneous.Date	 Provider No	  Treating Doctor.Provider Number			
		Name	Treating Doctor.Name			
		Address	 Practice.Address			
		Telephone	 Practice.Phone	 Fax	  Practice.Fax			
		Email	   MERGEFIELD BLANK 	 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 (4 points or more indicates moderate to high risk)		_______/8	
For the Berlin Questionnaire visit www.sleepdiagnostics.com.au/berlinquestionnaire