Sleep Study Referral

Patient Name

Patients DOB

Gender

Female

Male

Phone

Medicare/DVA No

Health Fund

Height (cm)

Weight (kg)

BMI (kg/m2)

What treatment?

Home Sleep Study/Periodic Limb Movement Study

Physician Sleep Study Consultation

CPAP Treatment Introduction

CPAP Treatment Review

Primary reasons for request (at least 2 are required):

STOP BANG Questionnaire

S-Does the patient SNORE loudly?

T- Does the patient often feel TIRED, fatigued or sleep during the day?

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 50years old?

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

G-Is the patient a MALE?

Epworth Sleepiness Scale Questionnaire
How likely is the patient to dose off or fall asleep, in contrast to just feeling tired? 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.

Sitting and reading

Watching television

Sitting inactive in a public place (eg Theatre or meeting)

As a passenger in a car for longer than 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

Requesting Doctor Name

Address

Phone

Provider Number

Date

Submit

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0401 317 181

CART

Sue Steiner

Yvonne Hughes