Adult Sleep Support Referral

GP's and Specialist Physicians, please complete the Adult Sleep Support Referral form.

Our staff will contact the patient to book an appointment for the home-sleep study.

All Medicare-subsidised sleep studies must meet the approved criteria outlined under Medicare Item 12250. The suitability and clinical appropriateness of home-based studies are reviewed and authorised by a supervising sleep physician.

Following assessment and review of study results, patients with more complex presentations may be referred for a specialist sleep physician consultation.

Date of referral *

Patient Details

Name *

Date of Birth *

Medicare No *

Phone number *

Address *Include any specifics re parking or access

STEP 1

Select Service (Tick all that apply)

Home Sleep Study CPAP Support

STEP 2

Please complete either the OSA50 Questionairre OR the STOP-BANG Questionnaire.

OSA50 Questionnaire

OSA50 Questionnaire (Tick all that apply)

OBESITY: Waist circumference - Males >102cm or Females >88cm. Measured at the level of the umbilicus.SNORING: Has the patients snoring ever bothered other people?APNOEAS: Has anyone observed the patient stop breathing or choking/gasping during their sleep?AGE: Is the patient aged 50 years or over?

OSA50 Questionnaire Total

STOP-BANG Questionnaire

Do you snore loudly? (e.g., louder than talking or loud enough to be heard through closed doors)

NoYes

Do you often feel tired, fatigued, or sleepy during the daytime?

NoYes

Has anyone observed you stop breathing during sleep?

NoYes

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

NoYes

Objective measures:

What is the patient's BMI?

≤35 kg/m²>35 kg/m²

What is the patient's age?

≤50 years>50 years

What's is the patient's neck circumference?

≤40 cm>40 cm

What's is the patient's gender?

FemaleMale

STOP-BANK Questionnaire Score

STEP 3

Please complete either the Epworth Sleepiness Scale.

Epworth Sleepiness Scale

How likely is the patient to doze off or fall asleep in the following situations, in contrast to feeling just tired?

Sitting and reading