Sleep & Respiratory – Referral Request
Patient Details
Name: <PtFullName> 	DOB: <PtDoB>
Phone: <PtPhoneMob> , <PtPhoneH>	 Email: <PtEmail>
Medicare: <PtMCNo> / <PtMCLine>, <PtMCExpiry>	 DVA: <PtDVANo>, <PtDVACard>
Address: <PtStreet><PtCity><PtPostcode>

Clinical History <CLINICAL HISTORY>
<Insomnia> Insomnia 
<Snoring> Snoring 
<Gasping/Choking> Nocturnal Gasping/Choking
<Witnessed Apneas> Witness apneas 
<Unrefreshed Sleep> Unrefreshed Sleep 
<Daytime Lethargy/Sleepiness> Daytime Lethargy/Sleepiness 
	<Restless Legs> Restless Legs 
<Sexual Disinterest> Sexual Disinterest 
<Bruxism/TMJ Pain> Bruxism/TMJ Pain 
<Axiety/Depression/PTSD> Anxiety/Depression/PTSD
<Concentration Issues> Concentration Issues
<Commerical Driver> Commercial Driver	<Cardiac History> Cardiac History
<CVA/Stroke> CVA / Stroke
<Hypertension> Hypertension
<Nocturia> Nocturia
<Diabetes> Diabetes
<Respiratory Disease> Respiratory Disease	
Clinical Notes / Extra Info: <Clinical Notes / Extra Info>
Our Services (National Service) <OUR SERVICES>
Sleep Services
<Full Sleep Investigation (Physician Consult & Home Sleep Test)> Full Sleep Investigation
      (Physician Consult & Home Sleep Test)
<Express Sleep Test (Requirements Apply - See MBS info sheet)> Express Sleep Test 
      (Requires apply - see overleaf)

Is test urgent?: <If urgent, reason:>	Services Provided
CPAP Initiation / Review <CPAP Initiation / Review>
24 Hour Blood Pressure Monitoring <24 Hour Blood Pressure Monitoring>
24 Hour SpO2 Monitoring <24 Hour SpO2 Monitoring>
Medicinal Cannabis Consult <Medicinal Cannabis Consultation>	
Specialist Physician Consultation Required 
<Physician Consult Initially - Allergies / Asthma> Allergy / Asthma
<Physician Consult Initially - Respiratory> Respiratory 
<Physician Consult Initially - Sleep> Sleep 		

Referring Doctor
Doctor Name: <DrName>  Provider#: <DrProviderNo>
Phone: <UsrPhone>   Email: <DrEmail>
Practice Name: <Practice>, <DrStreet>,<DrCity>,<DrState>,<DrPostcode>
Practice Email: <LocationEmail>  Practice Fax: <LocationFax>
Doctor Signature ………………………………………………..	Date of Referral: <TodaysDate>

Referring Doctors can have sleep test results sent directly to the referring doctor for management, without a Sleep / Respiratory Physician consult if the patient meets the following Medicare criteria. 

Alternatively, if the patient falls short of meeting the Medicare criteria, then a Full Sleep Investigation service will be required which includes a Sleep / Respiratory Physician consult for the patient to obtain their Sleep Test Results. 	Express Sleep Test Criteria requirements
Epworth Sleepiness Score ≥ 8  □
AND One of the following:
□ OSA50 ≥ 5    
OR
□ STOP-BANG ≥ 3  
OR
□ BERLIN QU. (tick if positive)  	

Epworth Sleepiness Questionnaire
How likely are you to dose off or fall asleep in the following situations, in contrast to sitting and reading just feeling tired?  This refers to your recent / current way of life.  Even if you have not done some of these things recently, try to determine how they would affect you.
Circle the response that best describes:	Never	Slight	Moderate	High	
Sitting and reading	0	1	2	3	
Watching television	0	1	2	3	
Sitting inactive in a public place (e.g. theatre or meeting)	0	1	2	3	
As a passenger in a car for an hour without a break	0	1	2	3	
Lying down to rest in the afternoon when circumstances permit	0	1	2	3	
Sitting and talking to someone	0	1	2	3	
Sitting quietly after lunch without alcohol	0	1	2	3	
In a car as a driver stopped for a few minutes in traffic	0	1	2	3	
		ESS Total =   _______/24	

STOP-BANG / OSA 50	STOP-BANG	OSA50	
Do you often feel tired, fatigued, or sleepy during the daytime?	+1	n/a	
Do you have (or are you being treated for) high blood pressure?	+1	n/a	
BMI > 35 kg/m2	+1	n/a	
Neck circumference > 43 cm  (Male)     
Neck circumference > 41 cm  (Female)	+1	n/a	
Gender Male?	+1	n/a	
Do you snore loudly? 	+1	+3	
Has anyone observed you stop breathing or choking/gasping during sleep?	+1	+2	
Age > 50 years	+1	+2	
Obesity: Waist circumference (male > 102cm, female > 88cm)	n/a	+3	
TOTAL			
 For the Berlin Questionnaire visit www.nextgentherapies.com.au/berlinquestionnaire