Perth Referral - In Home Sleep Study | Sleep Life Australia

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P: 08 6117 9339

E: reception@sleeplifeaustralia.com.au

F: 08 9200 5693

REQUEST FOR:

In Home Sleep Study

Level 2 PSG or Level 3 OSA Test

Patient Details

Patient Name:

DOB:

Address:

Telephone Number:

Pension:

DVA:

Medicare Number:

Ref:

Exp:

Email Address:

Tests Ordered

Level 2 PSG (Medicare Approved)

Level 2 PSG (Patient funded)

Level 3 OSA Test (Express service)

Please choose a Level 2 (Patient funded) or Level 3 (OSA Test) if the patient does not meet the Medicare requirements listed below.

Medicare Approved Assessment Conditions

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.

We can proceed with a patient funded Level 2 Sleep Study or Level 3 OSA Test if the patient does not meet the above requirements.

Sleep Assessment Tools

OSA50 Screening Questions - circle all that apply

(Score out of 10 and the referral requires 5+)

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

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

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

Referring Doctor's Details

Doctor's Name:

Address:

Practice Name:

Signature:

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Use your mouse or touch screen to sign in the box above

Provider No:

Date:

Patients with one or more of the following conditions are unsuitable for a home sleep study: Neuropsychological, severe intellectual or physical disability conditions or where video confirmation is essential for diagnosis (parasomnias / RLS).

Sleep apnea is serious and if untreated, you may be at a higher risk of a stroke, heart attack or a serious workplace accident. Having a detailed sleep study is the first step toward getting your liveliness back and living the life you deserve.

We provide an accurate and comprehensive take home sleep study allowing you to be in the comfort of your own bedroom environment. Your sleep study will be facilitated by qualified staff, scored by a sleep scientist and reported on by a sleep specialist. By dealing with us, you can expect quick results and expert advice on treatment options moving forward.

Additional Notes or Comments:

To book your sleep study with one of our clinicians

P: 08 6117 9339

E: reception@sleeplifeaustralia.com.au

F: 08 9200 5693

Our Midland clinic has moved to Midland Professional Centre (First Floor), Suite 8, 9 The Avenue, Midland WA 6056

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