Sleep & Respiratory Referral		

PATIENT NAME:<PtFirstName>	
Date of Birth:<PtDoB>	   GENDER:<PtGender>	MEDICARE NO: <PtMCNo>	
ADDRESS:<PtAddress>	
POSTCODE:<PtFull Address Postal>	TELEPHONE (H):<PtPhoneH>	MOBILE:<PtPhoneMob>	

SERVICES REQUESTED: 	CLINICAL DETAILS: <Practice/Location:Name>	
REFERRING DOCTOR DETAILS:
<DrName>
<DrStreet>	COPIES TO: <Copies To>	
DOCTOR SIGNATURE:	RESULTS
c Fax Report
cHealth Link Electronic Report	DATE (mandatory)
<Date>	
Medical practitioners can request our services online via www.sleepscope.com.au/ref
Referred For	
 Sleep & Respiratory Consultation
 Lung Function Test (17 years and older) (Combined Spirometry and Gas Transfer Factor)
 Home-based Sleep Study (18 years and older) [MBS 12250] - For initial diagnostic purposes, claimable once per year
    Please complete the Epworth Sleepiness Score and STOP-BANG Questionnaire to qualify for Medicare bulk billing.

EPWORTH SLEEPINESS SCALE (ESS)	STOP-BANG QUESTIONNAIRE	Yes	No	
Choose the most appropriate number for each situation:	Would never doze	

 0

SNORING: Do you snore loudly?	

Slight chance of dozing	

 1

Moderate chance of dozing	

 2

	
TIRED: Do you often feel tired, fatigued or sleepy during the daytime?	

High chance of dozing	

 3

OBSERVED: Has anyone observed you stop breathing during your sleep?	

	
Situation	
Chance of dozing (0–3)	

Sitting and reading	

	BLOOD PRESSURE: Do you have or are you being treated for high blood pressure?			
Watching television		BMI: Is your BMI more than 35kg/m2? (If unsure, please leave blank)			
Sitting inactive in a public place (e.g. a theatre or a meeting)		AGE: Are you over 50 years old?			
As a passenger in a car for an hour without a break		NECK CIRCUMFERENCE: Is your neck circumference greater than 40cm?			
Lying down to rest in the afternoon when circumstances permit		GENDER: Are you male?			
Sitting and talking to someone	

Sitting quietly after lunch without alcohol	

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

	Note:
MBS criteria for Medicare rebate:
Epworth Sleepiness Scale (ESS): ≥ 8 Points and
STOP-BANG Questionnaire: ≥ 3 Yes ticks.	

	APPOINTMENT DATE	

            /   /	

TIME            DATE           LOCATION 	

	
 Dr Hari Wimaleswaran 
MBBS, B.Physio, CCPU, FRACP	 Dr Rajiv Sharma
MBBS, FRACP	 Dr Hamna Sahi
MBBS, FRACP	 Dr Xun Li 
MBBS, MD, AMC, FRACP
	 Dr Vishnu Jeganathan
MBBS, FRACP

SLEEPSOPE CLINIC LOCATIONS	

SOUTH EAST	

	SRC
	HBSS
	LFT
	
Wheelers Hill 	Sleepscope Wheelers Hill	G1, 202 Jells Rd, Wheelers Hill 3150	x	x	x	
Dandenong	Sleepscope Dandenong 	40 Stud Rd, Dandenong 3175	x	x	x	
Pakenham	Sleepscope Pakenham	2 McGregor R, Pakenham 3810		x	x	
EAST						
Mooroolbark	Sleepscope Mooroolbark	Unit 1, 96 Manchester Rd, Mooroolbark 3138			x	
NORTH						
Thomastown	Sleepscope Thomastown 	113 High St, Thomastown 3074	x	x	x	
Coolaroo	Sleepscope Coolaroo	L1, Unit 103, 1510 Pascoe Vale Rd, Coolaroo 3048		x		
WEST						
St Albans	Sleepscope St Albans 	192 Furlong Road, St Albans 3021	x	x	x	
Werribee	Sleepscope Werribee	245 Heaths Rd, Werribee 3030		x	x	

SRC = Sleep and Respiratory Consultation
HBSS = Home-based Sleep Study
LFT = Lung Function Test	

	How to prepare Scan the QR code for information on preparing for your medical procedure.	
www.sleepscope.com.au/prep