HOME SLEEP STUDY REFERRAL
PATIENT DETAILS	
Title:	<<Patient Demographics:Title>>	Full name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>	
Date of Birth:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>	
Address:	<<Patient Demographics:Full Address>>	
Mobile No.:	<<Patient Demographics:Phone (Mobile)>>	Home phone No.:	<<Patient Demographics:Phone (Home)>>	
Referral Date:	<<Miscellaneous:Date>>	Medicare No.:	<<Patient Demographics:Medicare Number>>	
Driver’s License:	<<Driver's Licence Type? (Please select)>>	
REFERRAL TO A SLEEP PHYSICIAN RECOMMENDED FOR TRUCK OR COMMERCIAL DRIVERS
PATIENT PRESENTATION	
Snoring?	<<Snoring?>>	Type 2 diabetes?	<<Type 2 diabetes?>>	
Excessive daytime sleepiness?	<<Excessive daytime sleepiness?>>	Congestive Heart Failure?	<<Congestive Heart Failure?>>	
Nocturia?	<<Nocturia?>>	Narcolepsy?	<<Narcolepsy?>>	
Witnessed apnoeas?	<<Witnessed apnoeas?>>	Insomnia?	<<Insomnia?>>	
Depression?	<<Depression?>>	Abnormal movements in sleep?	<<Abnormal movements in sleep?>>	
Hypertension?	<<Hypertension?>>			
Clinical history: 
<<Clinical Details:History List>>	

INVESTIGATION REQUIRED	
Overnight ambulatory home-based sleep study for investigation of sleep apnoea
Comments: 

REFERRING DOCTOR	
Full Name:	<<Doctor:Name>>	
Practice Name:	<<Practice:Name>>	
Address:	<<Practice:Address>>	
Provider No.:	<<Doctor:Provider Number>>	Signed:		

STOP BANG Questionnaire
PATIENT PRESENTATION <<Please select all that apply>>	
S)nore	Do you snore?	<<Do you snore?>>	
T)ired	Do you feel tired during the day?	<<Do you feel tired during the day?>>	
	Do you wake feeling like you haven’t slept?	<<Do you wake feeling like you haven't slept?>>	
O)bstruction	Have you been told you stop breathing at night?	<<Have you been told you stop breathing at night?>>	
	Do you wake gasping or choking for air?	<<Do you wake gasping or choking for air?>>	
P)ressure	Do you have High Blood Pressure?	<<Do you have high blood pressure?>>	
	Are you on blood pressure medication/s?	<<Are you on blood pressure medication/s?>>	
If yes to 2 or more questions above, at risk of OSA	
B)MI	Is your Body Mass Index >28?	<<Is your Body Mass Index >28?>>	
A)ge	Are you 50 or more years old?	<<Are you 50 or more years old?>>	
N)eck	Are you a male with a neck circumference >43cm?	<<Are you a male with a neck circumference >43cm?>>	
	Are you a female with a neck circumference >41cm?	<<Are you a female with a neck circumference >41cm>>	
G)ender	Are you male?	<<Are you male?>>	
The more questions answered YES in the BANG portion, the higher the risk of having moderate to severe OSA.	
EPWORTH sleepiness scale (score 0-3 for each situation) <<Epworth Sleepiness Scale>>
What are the chances of you dozing off or falling asleep in the below scenarios? Feeling tired is not counted. The situations refer to your life recently. If you have not been doing some of these activities, decide how they would have affected you. Choose the most appropriate number from the following scale for each scenario.	
0 = No chance of dozing	1 = Slight chance of dozing	2 = Moderate chance of dozing	3 = High chance of dozing	
Sitting reading	<<Sitting reading>>	Lying down in the afternoon when circumstances allow	<<Lying down in the afternoon>>	
Watching TV	<<Watching TV>>	Sitting and talking to someone	<<Sitting and talking to someone>>	
Sitting inactive in a public place (e.g. meeting or theatre)	<<Sitting inactive in a public place>>	Sitting quietly after lunch without alcohol	<<Sitting quietly after lunch without alcohol>>	
Sitting in a car as a passenger for an hour without a break	<<Sitting in a car as passenger for an hour>>	Sitting in a car stopped in traffic for a few minutes	<<Sitting in a car in traffic for a few minutes>>	
Total score for the above situations:
0-10 Normal range
11-14 Mild sleepiness
15-17 Moderate sleepiness
>18 Severe sleepiness	
Total <<Select total score>>	
Could you please complete the above questionnaires with your patient? If they answer YES to 4 or more questions AND score 8 or more with the ESS they are eligible for an ambulatory in home sleep study to be billed through Medicare WITHOUT seeing a sleep physician first and this will be organised promptly (please include this form with the ambulatory referral letter). If they do not answer yes to 4 or more questions AND score 8 or more on the ESS, a sleep physician needs to review the patient prior to any home sleep study.
Referrals for in home ambulatory sleep studies may be sent via email, fax or in person.
Email: info@healthdynamics.com.au