ABN: 11 600 301 264	

	

Ph: 1300 559 583
Email: info@sleeptestingaustralia.com.au 
Fax: 1300 298 161

	REQUEST FOR:
In Home Sleep Test
Level 2 PSG or Level 3 OSA Test

Patient Details		Referring Doctor's Details	

Patient Name:	
<<Patient Demographics:Full Name>>	
M/F	

DOB:	
<<Patient Demographics:DOB>>	
Address:	
<<Patient Demographics:Full Address>>	

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

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

Medicare No:	
<<Patient Demographics:Medicare Number>>	
Ref:	

	
Exp:	
<<Patient Demographics:Medicare Expiry Date>>	

DVA Number:	
<<Patient Demographics:DVA Number>>	

	
Gold	

	
White	

		
Doctor:	
<<Doctor:Name>>	

Address:	
<<Doctor:Address>>	

	

Practice Name:	
<<Practice/Location:Name>>	

Signature:	

	

Provider No:	
<<Doctor:Provider Number>>	
Date:	
<<Miscellaneous:Date>>	

	

Medicare Approved Assessment Conditions	
1. Patient Aged 18+
2. OSA50 score of 5+   OR  STOPBANG score of 3+
3. Epworth Sleepiness Scale of 8+
4. Home Sleep Study has not been claimed within the last 12 months from the date of this referral.
For patients not meeting Medicare criteria, a pre-test specialist consultation can be requested	

TESTS ORDERED	

	
PSG SLEEP STUDY AMBULATORY - Level 2 Medicare Approved
Private studies available. Minors must be between the ages of 14-18	

	

SLEEP APNOEA SCREEN - Level 3 Private Pay

	

	
Pre-test consultation if Medicare criteria unmet	

	

OSAS0 Screening Questions
(Score out of 10 and the referral requires 5+)		STOPBANG Questionnaire
(Score out of 8 and the referral requires 3+)	
Circle all that apply	
If "yes" circle	

Waist circumference*
Male >102cm or Female > 88cm	

	
3 points

	

Snoring bothers others? 	

	
3 points

	

Witnessed apneas?	

	
2 points

	

Age 50 or over?	

	
2 points

	

Total OSA50 Score	
          Points	

*Waist measurement to be measured
at the level of the umbilicus		Does the patient Snore?	

	
1 point

	

Does the patient feel tired, fatigued or sleepy during the day time?	

	
1 point

	

Has anyone observed the patient stop breathing or choking/gasping during their sleep? 	

	
1 point

	

Is the patient being treated for high blood pressure?	

	
1 point

	

Is the patient's BMI greater than 35? 	

	
1 point

	

Is the patient's age 50 or older?	

	
1 point

	

Is the patient's neck circumference greater than 40cm?	

	
1 point

	

Is the patient's gender male?	

	
1 point

	

Total STOP BANG Score	
Points	

Epworth Sleepiness Scale (ESS) - Circle all that apply (Score out of 24 and the referral requires 8+)
In the following situations, how likely is the patient to doze off or fall asleep, in contrast to just feeling tired?
Use the numeric scale below to determine the likelihood of dozing off in each of the situations below.	
   0 = No Chance         1 = Slight Chance         2 = Moderate Chance         3 = High Chance	
Situations	Numeric Scale	
Sitting and Reading 	0	

	1	

	2	

	3	

Watching TV	0	

	1	

	2	

	3	

Sitting inactive in a public place	0	

	1	

	2	

	3	

As a passenger in a car for an hour with no break 	0	

	1	

	2	

	3	

Lying down in the afternoon	0	

	1	

	2	

	3	

Sitting and talking to someone	0	

	1	

	2	

	3	

Sitting quietly after lunch (without alcohol)	0	

	1	

	2	

	3	

Stopping in traffic for a few minutes while driving a car	0	

	1	

	2	

	3	

Total ESS Score	Out of 24	

Referral Reason	

	
Witnessed apnoea or choking	

	

Hypertension	

	

Depression	

	

Regular loud snoring	

	

Cardiac Disease/Arrhythmia	

	

Insomnia	

	

Regular Fatigue or Daytime Sleepiness	

	

Stroke	

	

Sleepy driving	

	

Obesity Height:_____cm Weight:_____kg	

	

Type II Diabetes	

	

Neurological Issues	

	

Frequent nocturia	

	

Other	

	

	

Patients with one or more of the following conditions are unsuitable for a home sleep study: Neuropsychological, severe intellectual or physical disability conditions or where video confirmation is essential for diagnosis (parasomnias / RLS). Sleep apnea is serious and if untreated, you may be at a higher risk of a stroke, heart attack or a serious workplace accident. Having a detailed sleep study is the first step toward getting your liveliness back and living the life you deserve. We provide an accurate and comprehensive take home sleep study allowing you to be in the comfort of your own bedroom environment. Your sleep study will be facilitated by qualified staff, scored by a sleep scientist and reported on by a sleep specialist. By dealing with us, you can expect quick results and expert advice on treatment options moving forward.	

To book your sleep study with one of our clinicians.	

	

ABN: 11 600 301 264	

	

Ph: 1300 559 583
Email: info@sleeptestingaustralia.com.au
Fax: 1300 298 161
Web: sleeptestingaustralia.com.au

	

	
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