Home Sleep Test Patient Referral Form
<<Doctor:Name>> <<Doctor:Qualifications>> 
Provider Number  <<Doctor:Provider Number>>
<<Doctor:Address>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>
Phone <<Doctor:Phone>> (All Hours) Fax <<Doctor:Fax>>  e-mail <<Doctor:E-mail>>
<<Miscellaneous:Date>>

Sleep Apnoea NQ
4/30 Bamford Lane
Kirwan QLD 4817
Ph: 0457 191 308
Fax: (07) 4422 0055	Reporting Physcian
Dr Geoffrey Williams
Medisleep
Suite 7&8, 70 River Street
Ballina NSW 2478	

Patient <<Patient Demographics:Full Name>>
D.O.B. <<Patient Demographics:DOB>> Our File No: <<Patient Demographics:Record Number>> Medicare No: <<Patient Demographics:Medicare Number>> Health Insurance <<Patient Demographics:Health Insurance>>
<<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:Postcode>> 
Phone No (home) <<Patient Demographics:Phone (Home)>> Phone No (work)<<Patient Demographics:Phone (Work)>> Phone No (mob) <<Patient Demographics:Phone (Mobile)>>

Sleep Study Eligibility Criteria
Witnessed Apnoea or Choking: <<Witnessed Apnoea or Choking>>				
Regular Loud Snoring: <<Regular Loud Snoring>>
Regular Fatigue or Sleepiness: <<Regular Fatigue or Sleepiness>>
CV Risk - Obesity (BMI >30), Hypertension, Cardiac Disease, Diabetes: <<CV Risk-Obesity,Hypertension,Cardiac dis,diabetes>> 
Epworth Sleepiness Scale: <<Epworth Sleepiness Scale Result:>> 	

ESS Questionaire:
For a medicare subsidised sleep study a patient must score 8 or more on the following.

How likely are you to doze off in the following situations:
0 - no chance	1 - slight chance	2 - Moderate chance	3 - High chance

Sitting and reading?							<<Likely to doze off - Sitting and reading>>	
Watching television?							<<Likely to doze off - Watching television>>
Sitting inactive, in a public space?						<<Likely to doze off -Sitting inactive, in a public space>>
Lying down to rest in the afternoon when circumstance permit?			<<Lying down to rest in the afternoon when circumsta>>
Sitting and talking to someone?						<<Likely to doze off - Sitting and talking to someone>>
Sitting quietly after lunch without alcohol?					<<Doze off - Sitting quietly after lunch without alcohol>>
As a passenger in a car for an hour without a break?				<<As a passenger in a car for an hour without a break>>
In a car, while stopped for a few minutes in traffic?				<<In a car, while stopped for a few minutes in traffic>>
							Total Score:	<<Total Score of above>>	

OSA 50 Screening Questionaire
For a medicare subsidised sleep study, a patient MUST score 5 or more on the following 
Obesity - waist circumference over 102cm (male) or over 88cm (female)? <<Obesity waist 102cm - Male 88cm - Female>> 	If answered yes - add 3 points		___/3
Snoring - Has your snoring ever bothered other people? <<Snoring - Has your snoring ever bothered other peo>>  		If answered yes - add 3 points		___/3
Apnoeas - Has anyone noticed that you stop breathing during your sleep? <<Apnoeas - Has anyone noticed that you stop breath>> 	If answered yes - add 2 points		___/2
50 - Are you aged 50 years or over? <<50 - Are you aged 50 years or over>>  				If answered yes - add 2 points 	___/2
										
										Total Score of above:________
	
Notes:
Please contact patient to arrange sleep monitoring.
Please send us report via mail.

Yours sincerely,

<<Doctor:Name>>