HOME SLEEP STUDY REFERRAL	HOBART | LAUNCESTON | DEVONPORT	

	HealthLink ID: hlthdtas
Fax: 03 4206 7880
Email: info@healthdynamics.com.au
www.healthdynamics.com.au	
HOBART	LAUNCESTON	DEVONPORT	
Suite 1,  2-8 Kirksway Place,
Battery Point   7004	173 Hobart Road, 
Kings Meadows, 7249	Shop 1, 142 William Street,
Devonport, 7310	
Ph 1300 731 615 	Ph 03 6343 1904	Ph 03 6423 2745	

 PATIENT DETAILS	
Title:	<<Patient Demographics:Title>>	Full Name:	<<Patient Demographics:Full Name>>	
DOB:	<<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Gender>>	 Pension Number:  <<Patient Demographics:Pension Number>>	
Address: <<Patient Demographics:Full Address>> 	
Phone number:  (h) <<Patient Demographics:Phone (Home)>> (m) <<Patient Demographics:Phone (Mobile)>> 		Drivers Licence Type:  <<Drivers Licence Type>>	
Medicare Card No: <<Patient Demographics:Medicare Number>>  Ref No: 		Expiry: <<Patient Demographics:Medicare Expiry Date>>	
 STOP BANG Questionnaire     (Yes or No for each question)	
 S)nore	 Do you snore?		
 T)ired	 Do you feel fatigued during the day AND/OR do you wake feeling like you haven't slept?		
 O)bstruction	 Have you been told you stop breathing at night AND/OR do you wake gasping or choking for air?		
 P)ressure	 Do you have high blood pressure AND/OR are you on blood pressure medications?		
B)MI Body Mass Index	 
Height cm	
	
 Weight kg	
	
  Is your Body Mass Index > 35 kg/m2?	

A)ge	 Are you 50 or more years old?		
N)eck	 Do you have a neck circumference  >40cm?		
G)ender	 Are you male?		
	TOTAL questions answered YES =		
EPWORTH sleepiness scale (Score 0-3 for each situation)

What are the chances of you dozing off or falling asleep in the below scenarios? Feeling tired is not counted. The situations refer to your life recently. If you have not been doing some of these activities, decide how they would have affected you. Choose the most appropriate number from the following scale for each scenario.	
0 = No chance of dozing          1 = Slight chance of dozing        2 = Moderate chance of dozing          3 = high chance of dozing	
 Sitting Reading		 Lying down in the afternoon when circumstances allow		
 Watching TV		 Sitting and talking to someone		
 Sitting inactive in a public place (e.g. meeting or theatre)		 Sitting quietly after lunch without alcohol		
 Sitting in a car as a passenger for an hour without a break		 Sitting in a car stopped in traffic for a few minutes	               	
	
             Total score for the above situations			
               0-10 Normal range,   11-14 Mild sleepiness,    15-17 Moderate sleepiness,   >18 Severe sleepiness	

Statewide Email: info@healthdynamics.com.au    |    Statewide Fax: 03 4206 7880 |   HealthLink ID: hlthdtas

HOME SLEEP STUDY REFERRAL	HOBART | LAUNCESTON | DEVONPORT	

	HealthLink ID: hlthdtas
Fax: 03 4206 7880
Email: info@healthdynamics.com.au
www.healthdynamics.com.au	
HOBART	LAUNCESTON	DEVONPORT	
Suite 1,  2-8 Kirksway Place,
Battery Point   7004	173 Hobart Road, 
Kings Meadows, 7249	Shop 1, 142 William Street,
Devonport, 7310	
Ph 1300 731 615 	Ph 03 6343 1904	Ph 03 6423 2745	

Please complete the above questionnaires with your patient. If they answer Yes to 4 or more questions in the STOP BANG AND score 8 or more with the ESS they are eligible for an ambulatory in home sleep study to be billed through Medicare WITHOUT seeing a sleep or respiratory physician first and this will be organised promptly. 
If they do not answer Yes to 4 or more STOP BANG questions AND score 8 or more on the ESS, a sleep physician needs to review the patient prior to any home sleep study due to Medicare requirements. 
SERVICE REQUESTED	
Diagnostic Home Sleep Study - to confirm diagnosis of Obstructive Sleep Apnoea and/or specialist consultation
 where deemed appropriate.

Patient Presentation  (Yes/No)	
 Excessive daytime sleepiness?			 Insomnia?			
						
Nocturia?			 Congestive Heart Failure?			
						
 Depression?			 *Narcolepsy?			
	
 Hypertension?			*Abnormal movements in sleep?			
	
Type 2 Diabetes?						
*Narcolepsy and parasomnias cannot be accurately diagnosed on an ambulatory study and will be redirected to a sleep physician.
 
 CLINICAL HISTORY (INCLUDING DETAILS OF ANY MOTOR VEHICLE ACCIDENTS AND OF ANY EPISODES OF FALLING ASLEEP WHILST DRIVING)	
<<Clinical Details:History List>>
	
 CURRENT MEDICATIONS	
<<Clinical Details:Medication List>>	

REFERRING DOCTOR	
Full Name:	 <<Doctor:Name>>   	Provider No. <<Doctor:Provider Number>> 		
Address:	  <<Doctor:Full Address>>   Ph: <<Doctor:Phone>>	
Signed:											Referral Date:  <<Miscellaneous:Date (short)>>	

Statewide Email: info@healthdynamics.com.au    |    Statewide Fax: 03 4206 7880 |   HealthLink ID: hlthdtas