Sleep Study Referral
info@bordersleepcentre.com.au
Wodonga Specialist Centre
216 Beechworth Rd, Wodonga, VIC 369
P (02) 6038 0830 W www.bordersleepcentre.com.au

Patient Details

First Name *

DOB

Last Name *

Gender

MaleFemale

Email

Phone number *

Address

Medicare Number

DVA Number

Age

Waist

Neck

Height

Weight

BMI

STOP-BANG Questions - tick all that apply

Total STOPBANG

OSA50 Questions - tick all that apply

Total OSA50

Referring Practitioner *

GPSpecialistDentistOther

Practitioner Name

Provider Number

Email

Fax

Address

Phone

Signature

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Date

EPWORTH SLEEPINESS SCALE

The Epworth Sleepiness Scale has been designed to measure a patient’s likely daytime sleepiness.

Total ESS Score

Contraindications To At Home Sleep Study

Have you previously failed or had an inconclusive unattended sleep study?

YesNo

Please give details

Do you have high anxiety about conducting a sleep study at home?

YesNo

Please give details

Do you have a suitable home environment to conduct this sleep study?

YesNo

Please give details

Do you have a physical or intellectual disability that affects conducting the sleep study?

YesNo

Please give details

Do you have any neuromuscular disease?

YesNo

Please give details

Do you have heart failure?

YesNo

Please give details

Have you ever suffered from advanced respiratory disease or respiratory failure?

YesNo

Please give details

Do you have any seizure disorders?

YesNo

Please give details

Have you or anyone else noticed unusual sleep behaviors?

YesNo

Please give details