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 *

Last Name *

Gender

MaleFemale

DOB

Email

Phone number *

Address

Medicare Number

DVA Number

Age

Height (cm)

Weight (kg)

BMI (kg/m²)

Neck (cm)

Waist (cm)

EPWORTH SLEEPINESS SCALE - See overleaf

Total ESS

STOP BANG Questions - tick all that apply

Snoring (1pt)

Have high blood pressure (1pt)

Neck, Male or Female > 40cm (1pt)

Observed stops breathing (1pt)

BMI over 35kg/m² (1pt)

Gender - Male (1pt)

Often tired, fatigued, or sleepy (1pt)

Aged over 50 (1pt)

Total STOPBANG

pdf_sb_snoring

pdf_sb_blood_pressure

pdf_sb_neck

pdf_sb_breathing

pdf_sb_bmi

pdf_sb_male

pdf_sb_tired

pdf_sb_age

OSA50 Questions - tick all that apply

Snoring bothers others (3pts)

Aged 50 or over (2pts)

Waist - Female > 88cm (3pts)

Observed stops breathing (2pts)

Waist - Male > 102cm (3pts)

Total OSA50

pdf_osa_snoring

pdf_osa_age

pdf_osa_waist_f

pdf_osa_breathing

pdf_osa_waist_m

Reasons for a Sleep Study

Depression

Acid reflux

Sleepy driving

Wakes with headache

Heart disease

Bruxing

Pre-surgery

Wakes unrefreshed

Stroke

Grinding

Libido loss

Wakes with dry mouth

Type II Diabetes

TMJ Pain

Urinating at night

Wakes choking, gasping, or coughing

How many times per night do you need to urinate (on average)? *

pdf_reason_depression

pdf_reason_reflux

pdf_reason_driving

pdf_reason_headache

pdf_reason_heart

pdf_reason_bruxing

pdf_reason_surgery

pdf_reason_unrefreshed

pdf_reason_stroke

pdf_reason_grinding

pdf_reason_libido

pdf_reason_drymouth

pdf_reason_diabetes

pdf_reason_tmj

pdf_reason_urination

pdf_reason_choking

Referring Practitioner *

GPSpecialistDentistOther

Practitioner Name

Provider Number

Email

Fax

Address

Phone

Signature

Draw signature|Type signatureClear

Date

Additional Clinical Information

EPWORTH SLEEPINESS SCALE

The Epworth Sleepiness Scale has been designed to measure a patient’s likely daytime sleepiness. How likely is the patient to doze off in the following situations? 0: None 1: Slight 2: Moderate 3: High

Total ESS

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

pdf_contra_failed

pdf_contra_anxiety

pdf_contra_environment

pdf_contra_disability

pdf_contra_neuromuscular

pdf_contra_heart_failure

pdf_contra_respiratory

pdf_contra_seizures

pdf_contra_behaviours