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Online Patient Risk Assessment Form

Please fill out the below assessment form. On submission you will be sent a copy of your filled out form and pre appointment checklist in preparation for your overnight home sleep study.

    YOUR DETAILS






    Select the clinic you are attending:

    WORK

    Are you a shift worker?:

    CARDIOVASCULAR HEALTH

    Have you had a heart attack or stroke?:

    Do you suffer from chronic heart failure?:

    Do you have a history of heart disease?:

    DRIVING HISTORY

    Do you hold a commercial driver's license?
    (Taxi, Uber, Bus, Commercial Truck):

    Do you hold a heavy vehicle drivers license?:

    Have you ever fallen asleep whilst driving?
    (Operating a motor vehicle while sleep or drowsy):

    GENERAL HEALTH

    Do you drink caffeine after midday?:


    Do you drink alcohol:


    Do you or have you ever smoked cigarettes?:



    MEDICATIONS

    Are you currently taking any medications?

    ELIGIBILITY

    I am eligible for NDIS funded subsidies for sleep apnoea treatment
    I am eligible for HCP subsidies for sleep apnoea treatment

    Patient Consent Form

    We collect information from you for the primary purpose of providing a health service to you. We require you to provide us with your personal details and medical history so that we may properly assess, diagnose, treat and be proactive in your healthcare needs. In accordance with the Australian Privacy Act (Cth 1988) we will use the information you provide in the following ways:

    • Administrative purposes in running our clinical practice.
    • Billing purposes, including compliance with Medicare and Health Insurance Commission requirements.
    • Disclosure to others involved in your healthcare, including your referring doctor and primary care physician (GP). Other health professionals outside this practice can be given your personal and health information only as advised by you.
    • Disclosure to authorised contractors and employees (including reporting sleep scientists, sleep physicians and sleep therapy providers) in order to provide services and information to you about your sleep diagnosis and therapy options should you require it.

    Sleep Testing Australia (as a sleep diagnostics services division of CPAP Direct Pty Ltd) may keep your personal information with third parties that we rely on to deliver services to you. Third parties may include our medical device suppliers software, payment gateway services, patient booking system and practice management system providers.
    We offer our patients an opportunity to discuss their sleep study report with a trained sleep health clinician. Information given to you during these consultations is to provide you with a better understanding of the results and to provide an explanation of the sleep physician’s conclusion and reasons for their recommendations.
    As per the Health Practitioner Regulation National Law Act (Qld 2009) our sleep health clinicians are not registered health practitioners, and their advice should therefore not be interpreted as medical advice. Sleep Testing Australia strongly recommends all patients see a registered health practitioner qualified to give advice on sleep disorders and sleep disorder management (ie. a general practitioner and/or sleep physician).

    As part of a home based sleep study, you will be issued a sleep recording device that goes home with you. You are required to return the recording device (inclusive of all recording sensors that were issued to you) the next day. If the recording device is damaged, lost or not returned, you are liable to pay Sleep Testing Australia the costs of recovering, replacing or repairing the recording device (including the costs for replacing lost or damaged sensors).
    More information can be found in Sleep Testing Australia’s Privacy Policy at www.sleeptestingaustralia.com.au

    By signing below;
    • I understand the reasons why my information must be collected.
    • I understand that I am not obliged to provide any information requested of me, but that my failure to do so might compromise the quality of the healthcare and services given to me.
    • I am aware of my right to access the information collected about me, except in circumstances where access might legitimately be withheld. I understand I will be given an explanation in these circumstances.
    • I understand that if my information is to be used for any purpose other than the above, my consent will be sought.
    • I understand that information received from Sleep Testing Australia’s sleep health clinicians about my sleep study report should not be construed as medical advice as it is not given by a registered health practitioner.
    • I understand that should I fail to return or inflict damage to the recording device that I am liable for the costs of repair / replacement of the device.





    Patient Signature