Sleep Support Referral Form

Adult Sleep Support Referral

GP's and Specialist Physicians, please complete the Adult Sleep Support Referral form.

Our staff will contact the patient to book an appointment for the home-sleep study.

All Medicare-subsidised sleep studies must meet the approved criteria outlined under Medicare Item 12250. The suitability and clinical appropriateness of home-based studies are reviewed and authorised by a supervising sleep physician.

Following assessment and review of study results, patients with more complex presentations may be referred for a specialist sleep physician consultation.

Date of referral(Required)

MM slash DD slash YYYY

Patient Details

Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Medicare No(Required)

Phone number(Required)

Address(Required)

Step 1

Select Service (Tick all that apply)

Home Sleep Study

CPAP Support

Step 2

Please complete either the OSA50 Questionairre OR the STOP-BANG Questionnaire.

OSA50 Questionnaire (Tick all that apply)
OBESITY: Waist circumference - Males >102cm or Females >88cm. Measured at the level of the umbilicus. (3 points)
SNORING: Has the patients snoring ever bothered other people? (3 points)
APNOEAS: Has anyone observed the patient stop breathing or choking/gasping during their sleep? (2 points)
AGE: Is the patient aged 50 years or over? (2 points)

OSA50 Questionnaire Total

STOP-BANG Questionnaire

Do you snore loudly? (e.g., louder than talking or loud enough to be heard through closed doors)

No (0 points)

Yes (1 point)

Do you often feel tired, fatigued, or sleepy during the daytime?

No (0 points)

Yes (1 point)

Has anyone observed you stop breathing during sleep?

No (0 points)

Yes (1 point)

Do you have (or are you being treated for) high blood pressure?

No (0 points)

Yes (1 point)

STOP-BANK Questionnaire Score

Objective measures:

What is the patient's BMI?

≤35 kg/m²

>35 kg/m²

What is the patient's age?

≤50 years

>50 years

What's is the patient's neck circumference?

≤40

>40

What's is the patient's gender?

Female

Male

Step 3

Please complete either the Epworth Sleepiness Scale.

Epworth Sleepiness Scale

How likely is the patient to doze off or fall asleep in the following situations, in contrast to feeling just tired?

Sitting and reading

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Watching TV

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Passenger in a car trip

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Sitting and talking to someone

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Sitting inactive in public (meeting or theatre)

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Lying down in the afternoon when able

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Sitting after lunch without alcohol

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

In a car stopped in traffic for a few minutes

Would never doze off (0 points)

Slight chance of dozing off (1 point)

Moderate chance of dozing off (2 points)

High chance of dozing off (3 points)

Epworth Sleepiness Scale Score

If the Epworth Sleepiness Scale score is ≥ 8 AND either the OSA50 Questionnaire score is ≥ 5 OR the STOP-BANG Questionnaire score is ≥ 3, the patient is eligible for a sleep study with full rebate, and may be evaluated by a sleep physician.

Step 4

How does the patient present? (Tick all that apply)
Unexplained sleepiness (adequate sleep hygiene and environment)
Active cardiac disease/arrhythmia
Possible movement disorder (no RLS)
Adequate sleep hypoventilation
Possible parasomnia
Acromegaly or thyroid disease
Possible central sleep apnoea
Unsuitable home environment

ELIGIBILITY FOR MEDICARE SUBSIDISED STUDY

Does the patient meet the requirement for a medicare subsidised home-based sleep study?

Yes: The patient meets eligibility criteria. Please submit the referral for review and approval by a supervising sleep physician, and to arrange a home sleep study.

No: The patient does not meet eligibility criteria. Please submit the referral to discuss alternative sleep study options. A private fee may apply.

Referring Doctor's Details

Name(Required)

Clinic Name(Required)

Clinic Address(Required)

Provider No:(Required)

Signature