Ph: 0402956871,  0411758267
Fax (03) 8678 1188
	
   Home Sleep Study Referral Form (pls fax to 03 8678 1188)
Patient Details	Referring Doctor Details	
Name: <PtName>	 Name: <DrName>	
Address: <PtAddress>	 Clinic: <Practice>
	<DrAddress>	
Telephone: (h) <PtPhoneH>	 Provider No:  <DrProviderNo> 	
		(m) <PtPhoneMob>	 Phone/Fax: <DrPhone>  <DrFax>	

Date: <TodaysDate>	
Signature: 	

STOP-BANG Sleep Apnoea Questionnaire (Minimum 3 yes required)
Do you SNORE loudly (louder than talking or loud enough to be
heard through closed doors)?	Yes/ No	
Do you often feel TIRED fatigued or sleepy during daytime? 	Yes/ No	
Has anyone OBSERVED you stop breathing during your sleep?	Yes/ No	
Do you have or are your being treated for high Blood PRESSURE?	Yes/ No	
BMI more than 35kg/ m2?	Yes/ No	
AGE over 50 years old? 	Yes/ No	
NECK circumference > 15 inches (40 cms)?	Yes/ No	
GENDER: Male? 	Yes/ No	

Total Score		
  High Risk of OSA : yes to 5-8, Moderate Risk of OSA : yes to 3-4, Low Risk of OSA : yes to 0-2

Epworth Sleepiness Scale (ESS) (minimum 8 score required)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? Use the
following scale to choose the most appropriate number for each situation:
0= no chance of dozing: 1= slight chance of dozing : 2= moderate chance of dozing : 3= High chance of dozing
Situation	Score	
 Sitting and reading		
 Watching TV		
 Sitting inactive in a public place ( eg a theatre or a meeting )		
 As a passenger in a car for an hour without a break		
 Lying down to rest in the afternoon when circumstances permit		
 Sitting and talking to someone		
 Sitting quietly after lunch without alcohol		
 In a car while stopped for a few minutes in traffic		

TOTAL		

   Dr Anuk Kruavit     5508595Y	     FAX: 03 8678 1188	     Dr Ngoc Tran     064217KJ