Sleep Study 
Referral Form

Phone
Fax
Email	
0436 141 400
(08) 8431 4734
contact@aboutsleep.com.au	

	
Eastern Clinic
L1 290 Glen Osmond Road
Fullarton SA	
Western Clinic
5/95 Findon Road
Woodville South SA	
Southern Clinic
760 Marion Road
Marion SA	
Northern Clinic
4/502 North East Road

	
Please send us this referral by email, fax, post or drop it into one of our clinics.
We will contact the patient to book this sleep study.
Patient needs to be over 18 and not have had a sleep study within the past 12 months. No gap will be charged. Patient to sleep in
their own home after either wiring themselves up or being wired in our clinics in the afternoon.	
Patient Details	
Name	<PtFirstName> <PtSurname>	Date of Birth	<PtDoB>	
Address	<PtStreet> <PtCity> <PtPostcode>	
Phone	<PtPhoneMob>	Email	<PtEmail>	
Medicare Number	<PtMCNo>	Position on Card	<PtMCLine>	
STOP- BANG <STOP- BANG>	
<Snoring Loudly (Louder than talking?)>	
Snoring Loudly (Louder than talking?)	
STOP-BANG OSA RISK

0-2 Low Risk
3-4 Moderate Risk
5-8 High Risk

STOP-BANG Score  <STOP-BANG Score - / 8> / 8
OSA-50 Score   <OSA-50 Score -  /10> / 10 See Overleaf
ESS Score   <ESS Score -  / 24> / 24 See Overleaf	

<Often Feel Tired, Fatigued or Sleepy?>	
Often Feel Tired, Fatigued or Sleepy?	

<Observed Apnoeas?>	
Observed Apnoeas?	

<High Blood Pressure?>	
High Blood Pressure?	

<BMI > 35kg/m2>	
BMI > 35kg/m2	

<Age Over 50?>	
Age Over 50?	

<Neck Circumference > 40cm>	
Neck Circumference > 40cm	

<Gender Male?>	
Gender Male?	

	
Specialist <Specialist>	
�	Please choose a specialist for the patient based on their address and best waiting times. 
�	I request the following Sleep Specialist:	
<Dr Michael Chia (Kent Town, Elizabeth)>	Dr Michael Chia (Kent Town, Elizabeth)	<Dr Hooi Shan Yap (Brighton, Gawler)>	Dr Hooi Shan Yap (Brighton, Gawler)	
<Dr Sutapa Mukherjee (Adelaide)>	Dr Sutapa Mukherjee (Adelaide)	<Dr Michelle Tan (Ashford, Windsor Gardens, Adelaide)>	Dr Michelle Tan (Ashford, Windsor Gardens, Adelaide)	
<Dr Carissa Yap (Kent Town)>	Dr Carissa Yap (Kent Town)	<Dr Aaron Oh (Adelaide, Stirling)>	Dr Aaron Oh (Adelaide, Stirling)	
<Dr Nur Sulaiman (Woodville, Norwood)>	Dr Nur Sulaiman (Woodville, Norwood)	<Dr Sowmya Krishnan (Ashford, Pennington)>	Dr Sowmya Krishnan (Ashford, Pennington)	
<Dr Simon Proctor (Brighton, Hove, Wallaroo)>	Dr Simon Proctor (Brighton, Hove, Wallaroo)	<Dr Vanessa Tee (Adelaide, Gawler)>	Dr Vanessa Tee (Adelaide, Gawler)	

Referring Doctor Name	<DrName>	Referring Doctor Provider Number	<DrProviderNo>	
Address	<UsrAddress>	
Phone	<UsrPhone>	
Fax / Email	<PracEmail>	

Signature		Date	<TodaysDate>	

OSA - 50 <OSA - 50>	

	Y / N	Points	
Obesity	Waist circumference* - Male > 102cm or Females 88cm	<Obesity>	3	
Snoring	Has your snoring ever bother other people?	<Snoring>	3	
Apnoeas	Has anyone noticed that you stop breathing during sleep?	<Apnoeas>	2	
50	Are you aged 50 years or over?	<50?>	2	
	
Score >=5 Moderate to High Risk OSA	Total Score	   /10 points	
* Waist measurement to be measured at the level of the umbilicus
The Epworth Sleepiness Scale <The Epworth Sleepiness Scale>	
How likely are you to doze off or fall asleep in the following situations? Even if you have not done some of these things recently, please try to determine how they would have affected you.
Use the following scale to choose the most appropriate score for each situation:	
0 = would never doze
2 = moderate chance of dozing	1 = slight chance of dozing
3 = high chance of dozing	

Situation	Score	
Sitting and Reading	<Sitting and Reading>	
Watching TV	<Watching TV>	
Sitting inactive in a public place	<Sitting inactive in a public place>	
A passenger in a car for an hour without a break	<A passenger in a car for an hour without a break>	
Lying down to rest in the afternoon when circumstances permit	<Lying down to rest in the afternoon when circumstances permit>	
Sitting and talking to someone	<Sitting and talking to someone>	
Sitting quietly after lunch without alcohol 	<Sitting quietly after lunch without alcohol>	
In a car while stopped for a few minutes in traffic	<In a car while stopped for a few minutes in traffic>	
Total	<The Epworth Sleepiness Scale Total>	
11 – 12 Mild Excessive Daytime Sleepiness
13 – 15 Moderate Excessive Daytime Sleepiness
16 – 24 Severe Excessive Daytime Sleepiness