Albany Referral - Sleep Study | Sleep Life Australia

Need a printable blank version?

Download Blank Referral Form

P: 08 6117 9339

E: reception@sleeplifeaustralia.com.au

F: 08 9200 5693

SLEEP REFERRAL FORM:

Dr Helen Bell

MBBS MSc FRACP

Referral doubles as general referral to Dr Helen Bell and/or Referral to SLA for sleep assessment.

Patient Details

Patient Name:

DOB:

Address:

Telephone Number:

Pension:

DVR:

Medicare Number:

Ref:

Exp:

Email Address:

Referral For:

Level 2 Ambulatory sleep study

And/Or

Sleep Physician consultation

If patient does not meet Medicare criteria for direct sleep study a consultation with Dr Helen Bell will be offered followed by Medicare approved sleep study if indicated.

URGENT?

Reason?

Medicare Criteria for Direct Sleep Study

Patient Aged 18+
OSA50 score of 5+ OR STOPBANG score of 3+
Epworth Sleepiness Scale of 8+
Home Sleep Study has not been claimed within the last 12 months from the date of this referral

Referral Reason

Clinical History (required)

Please attach a list of current medications.

To book your sleep study with one of our clinicians

P: 08 6117 9339

E: reception@sleeplifeaustralia.com.au

F: 08 9200 5693

Albany

137 Grey St West

Albany WA 6330

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
	0	1	2	3
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour with no break
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (without alcohol)
Stopping in traffic for a few minutes while driving a car
Total ESS Score	0 Out of 24

Sleep Assessment Tools

OSA50 Screening Questions - circle all that apply(Score out of 10 and the referral requires 5+)

	If "yes" circle
Waist circumference* - Male > 102cm or Female > 88cm	Yes No 3 Points
Snoring bothers others?	Yes No 3 Points
Witnessed apnoeas?	Yes No 2 Points
Age 50 or over?	Yes No 2 Points
Total OSA50 Score	0 Points

*Waist measurement to be measured at the level of the umbilicus

Our Locations

Wanneroo

Drovers Medical Centre (First Floor)

14/1397 Wanneroo Rd

Wanneroo WA 6065

Murdoch

Murdoch Professional Centre

4/6 Robson Way

Murdoch WA 6150

Midland

Midland Professional Centre (First Floor)

Suite 8, 9 The Avenue

Midland WA 6056

Albany

Albany & Greater Southern Region

137 Grey Street West

Albany WA 6330

By submitting this form, you confirm that all information provided is accurate and complete. This information will be encrypted and securely stored.

Does the patient Snore?	Yes No	1 Points
Does the patient feel tired, fatigued or sleepy during the day time?	Yes No	1 Points
Has anyone observed the patient stop breathing or choking/gasping during their sleep?	Yes No	1 Points
Is the patient being treated for high blood pressure?	Yes No	1 Points
Is the patient's BMI greater than 35?	Yes No	1 Points
Is the patient's age 50 or older?	Yes No	1 Points
Is the patient's neck circumference greater than 40cm?	Yes No	1 Points
Is the patient's gender male?	Yes No	1 Points
Total STOP BANG Score		0 Points

Patient Details

Referral For:

Medicare Criteria for Direct Sleep Study

Referral Reason

Indication (tick box)

Clinical History (required)

Referring Doctor's Details

Relevant Medical Conditions

Epworth Sleepiness Scale (ESS) - circle all that apply(Score out of 24 and the referral requires 8+)

STOPBANG Questionnaire - circle all that apply(score out of 8 and the referral requires 3+)

Sleep Assessment Tools

OSA50 Screening Questions - circle all that apply(Score out of 10 and the referral requires 5+)

Our Locations