Sleep Study Referral Form

Complete all sections for a comprehensive sleep assessment

Page 1: Patient & Assessments

Page 2: Epworth & Referral Details

Review & Submit

Page 1: Patient & Assessments

Step 1 of 3

First Name *

Middle Name

Last Name *

Date of Birth *

Age

Gender

Male

Female

Other

Email *

Phone *

Address

City

State

Postcode

Medicare Details

Medicare Number

0/10 digits

Medicare Ref

Medicare Expiry

Pension Number

DVA Number

Tests Ordered

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

Level 2 PSG (Medicare Approved)

Level 2 PSG (Patient funded)

Level 3 OSA Test (Express service)

Medicare Approved Assessment Conditions

Patient Aged 18+
OSA50 score of 5+ OR STOPBANG score of 4+
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+)

	If "yes" circle
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

Waist circumference* - Male >102cm or Female > 88cm

3 points

Yes

Snoring bothers others?

3 points

Yes

Witnessed apnoeas?

2 points

Yes

Age 50 or over?

2 points

Yes

Total OSA50 Score

0 Points

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

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

Sleep Study Referral Form

Page 1: Patient & Assessments

Medicare Details

Tests Ordered

Medicare Approved Assessment Conditions

Sleep Assessment Tools

OSA50 Screening Questions - circle all that apply

STOPBANG Questionnaire - circle all that apply