Referral to Sleep Specialist              	
			
☐ Dr Krishan Gupta          	Sleep Dynamics	OFFICE: 02 4044 1260	
EMAIL: referrals @sleepdynamics.com.au	PO Box 2050 Gateshead 2290	FAX: 02 4044 1263	
Patient Information	
Patient Name:     	DOB:  	Mobile:   	
Telephone:   	Email:   	
Address:   	
Health Fund: 	Medicare No/DVA No:  	
Request	
☐   Consultation	☐     Overnight Oximetry	☐      CPAP/APAP Treatment Trial	
☐   Consultation/ PSG Sleep Study
	☐     Lab Based PSG / Titration	☐      Bi Level Trial
	
☐   Lifestyle Modification Program	☐     Mandibular Splint 	☐      MSLT/MWT	
Medical Co-Morbidities  ( Please complete as Appropriate) 
Height (cm)  = 	
Type 2 Diabetes ☐     AF ☐     Cardiac ☐	
Previous Sleep Study	

Weight (kg)  =	
Stroke/TIA ☐    COPD ☐  Depression/Anxiety ☐	
Yes ☐       No ☐	

BMI (kg/m2) =	
Other:	
Date     /    /	

Epworth Sleepiness Scale Questionnaire
For the 8 situations in the table below, how likely is the patient to doze off or fall asleep. Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze, 1= Slight chance of dozing, 2= Moderate chance of dozing, 3= High chance of dozing.
Situation	
Score	
	
                                        New Medicare guidelines require careful patient screening prior to determining the most appropriate test/ consultation. Direct testing may be appropriate if the patient has a high probability for moderate-severe OSA: Epworth Sleepiness Scale of 8 or more and a score of 4 or more on a validated STOP BANG questionnaire	

Sitting and reading	

	

Watching Television	

	

Sitting inactive in a public place (eg cinema, meeting or waiting room)	

	

Passenger in a car for > 1 hour without a break	

	

Lying down to rest in the afternoon when circumstances permit	

	

Sitting and talking to someone	

	

Sitting quietly after lunch without alcohol	

	

In a car stopped for a few minutes in traffic	

	

TOTAL ESS SCORE:	
         /24	

STOP BANG Questionnaire  ( Please Tick)                           
S – Does the patient SNORE loudly?                          ☐	
B – Does the patient have a BMI higher than 35? ☐	

T – Does the patient often feel TIRED, fatigued or 
Sleepy during the day?                                             ☐   	
A -AGE over 50 years old                                   
                                                                       ☐    	

O – Has anyone OBSERVED the patient stop 
breathing in their sleep?                                           ☐                  	
N – NECK Circumference (shirt size) more
than 40 cm/16 inches                                        ☐     	

P – Does the patient have or is the patient 
being treated for high blood PRESSURE?                    ☐	
G – Is the patient a MALE?                                 ☐                                
                                           TOTAL SCORE:     /8                                                                   	

Referring Physician Details	

Referring Physician:	
Practice:	

Provider Number:	
Address:	

Signature:	
Phone:	

CC:                                              Date:	
Email: