Sle	Sleep Study Referral	

Patient Details	

Name:	<<Patient Demographics:Full Name>>	

	Telephone 1:	<<Patient Demographics:Phone (Mobile)>>	

Address:	<<Patient Demographics:Full Address>>	

	Telephone 2:	<<Patient Demographics:Phone (Home)>>	

City:	<<Patient Demographics:City>>	
State:	
<<Patient Demographics:State>>	
Postcode:	
<<Patient Demographics:Postcode>>	

	  Email:	<<Patient Demographics:E-mail>>	

Medicare No/DVA No:	<<Patient Demographics:DVA Number>>	

	  DOB:	<<Patient Demographics:DOB>>	

	Healthfund:		

Referring Doctor Details*(all referrals must be signed and dated for medical purposes)	

Stamp:	

	

Signature*:	

	
   Date:	
<<Miscellaneous:Date>>	

	

	Name:	
<<Doctor:Name>>	

	

Provider No:	
<<Doctor:Provider Number>>	

	

Telephone:	
<<Doctor:Phone>>	

Fax:	
<<Doctor:Fax>>	

	

Address:	
<<Doctor:Address>>	

	

suburb:	
<<Doctor:City>>	

Postcode:	
<<Doctor:Postcode>>	

	

Service Requested	

Diagnostic Sleep Study - to confirm diagnosis of Obstructive Sleep Apnea and specialist consultation where deemed appropriate by the sleep physician 
Clinical history:	<<Clinical Details:History List>>	

	

	

Medical Co-Morbidities (Please complete as appropriate)	
Height (cm)  =	

	

Weight (kg)  =	

	

BMI (kg/m2) =	

	

	
Type 2 diabetes	

	
AF	

	
Cardiac failure	

	
Stroke/TIA	

	
COPD	

	

	

	

	

Other Co-Morbidities:	

	

	

	

	

	
   Previous sleep study: 

	
Yes	

	
No	

Date:	

	

Medicare Guidelines Criteria (STOPBang OR OSA50 AND Epworth Sleepiness Scale Questionnaire)	

STOP-Bang1 : A score of > 3	OSA502 : A score of > 5	

	
S – Does the patient SNORE loudly? 	

	
T – Does the patient often feel TIRED, fatigued or sleep during daytime?	

	
O – Has anyone OBSERVED the patient stop breathing during sleep?	

	
P – Does the patient have or is the patient being treated for high blood PRESSURE?	

	
B – Does the patient have a BMI more than 35?	

	
A – AGE over 50 years old	

	
N – NECK circumference (shirt size) more than 40cm / 16 inches	

	
G – Is the patient a MALE? 	

Each question is 1 score	
TOTAL score	

	

	or		

O	
Obesity (3)	
Waist circumference:  
Male > 102cm or Female >88cm	

	
S	
Snoring (3)	
Has your patient’s snoring ever  bothered other people?	

	
A	
Apnea (2)	
Has anyone noticed that your patient stopped breathing during sleep?	

	
50	
  (2)	
Is your patient aged 50 years or over?	

() = score	
TOTAL score	

	

	

Epworth Sleepiness Scale3 Questionnaire: A score of > 8	

Scenario	
Tick one score for each scenario	

Score	
0	
1	
2	
3	

Sitting and reading	

	

	

	

	

Watching television 	

	

	

	

	

Sitting inactive in a public place (eg. theatre or meeting) 	

	

	

	

	

As a passenger in a car for an hour without a break 	

	

	

	

	

Lying down in the afternoon when circumstances permit 	

	

	

	

	

Sitting and talking to someone	

	

	

	

	

Sitting quietly after lunch without alcohol 	

	

	

	

	

In a car, while stopped for a few minutes in traffic 	

	

	

	

	

TOTAL SCORE (add up total responses) 	

	

	For the 8 situations in the table below, how likely is the patient to doze off or fall asleep, in contrast to feeling just tired? 
Even if the patient has not done some of these things recently, ask them how the situations would have affected them.
Use the following scale to choose the most appropriate number for each situation:
0=Would never doze
1=slight chance of dozing
2=moderate chance of dozing
3=high chance of dozing
Then total the scores. 
1Chung Fetal Anaesthesiology 2008 & Br J Anaesth 2012;
2Chai-Coetzer CL ed al Thorax 2011; 3Johns M Sleep 1991

	
	
EFAX 1800 270 779  |  Medical Objects ID: LA2015OOOJD  |  HealthLink ID: alhealth  |  sleepstudy@airliquide.com
Our staff will contact the patient to book a convenient appointment if the referral is sent using one of the above options.     	

	

Sle	

ON THE DAY OF THE SLEEP STUDY
• No nail polish or acrylic fingernails
• A credit card may be required to cover a fully refundable security deposit for the test device to cover a fully refundable security deposit for the test device