Tasmanian Health Service 
ROYAL HOBART HOSPITAL
GPO Box 1061, HOBART TAS 7001, Australia
Ph: (03) 6166 0000
Fax: (03) 6234 3982
Web: www.dhhs.tas.gov.au

RHH Sleep Clinic Referral 

Patient Details 	

Name: <PtFullName>	Telephone 1:	<PtPhoneH>	
Address: <PtAddress>	Telephone 2:	<PtPhoneMob>	
Health Care Card/CRN Number: <PtPensionNo>	DOB:	<PtDoB>	
	Nocturnal hypoventilation/Respiratory Failure:	<Nocturnal hypoventilation/Respiratory Failure?>	

Clinical History	

<SelectedPMH>

Medical Co-Morbidities (please complete as appropriate)	

Height (cm) = <Height (cm)?>
Weight (kg) = <Weight (kg)?>
BMI (kg/m2) = <BMI (kg/m2)?>	<Medical Co-Morbidities?>	<Other Co-Morbidities>	

Epworth Sleepiness Scale	Referring Doctor	

How Likely are you to doze off or fall asleep in the following situations? 
Use the following scale to choose the most appropriate number: 
 	Name:
Provider #:
Unit: 
Phone:
Date: 	 <DrName>
 <DrProviderNo>

 <DrPhone>
<TodaysDate>	

0           |           1          |          2          |          3
         no chance              slight chance        moderate chance       high chance	
Signature:	

	
Sitting and reading 	

Watching television	

Sitting inactive, in a public space	

Lying down to rest in the afternoon	

Sitting and talking to someone	

Sitting quietly after lunch without alcohol	

As a passenger in car for an hour without break	

In a car, while stopped for a few minutes in traffic	

Total Score	

		Please fax this referral to 
RHH Outpatient Clinics: 
6234 3982 	

STOP-Bang Questionnaire: Please answer the following questions by checking 'Yes' or 'No' for each one. 
	
Yes	
No	

Snoring (Do you snore loudly?)	

Tiredness (Do you often feel tired, fatigued, or sleepy during the daytime?)	

Observed Apnea (Has anyone observed you stop breathing, choke or gasp during sleep?)	

High Blood Pressure (Do you have or are you being treated for high blood pressure?)	

bMI (is your Body Mass Index maore than 35kg per M2?)	

Age (Are you older than 50 years?)	

Neck Circumference (is your neck circumference greater than 40 cm?)	

Gender (are you male?)	

Total Score 	

Chung F et al Anaesthesiology 2008:108(5): 812-21&Br J Anaesth 2012:108(5): 768-75 Johns M Sleep 1991:14(6):540-545 	Outpatient Use Only