Date of referral

South Eastern Private Hospital Sleep Study Referral

Referrer information

Given name *

Family name *

Provider number

Provider qualification

If other qualification, please enter here *

I would like to be kept informed by *

EmailLetterPhoneFax

Practice phone number *

Practice fax number

Practice name

Please provide your email if you wish to receive a copy of this referral submission

If this referral is being completed by a registrar or intern, details of the referring consultant must be provided below

Consultant given name

Consultant family name

Consultant Provider Number

Patient Information

Given name *

Family name *

Date of Birth *

Medicare number

Medicare Reference Number

Patient phone number *

Patient email

Patient address

City

State

Postcode

Funding source

Private Health Fund

Health fund policy number

DVA membership number

Workers compensation claim number

Insurer name

Case Manager

TAC claim number

If other, please specify

Referral Information

The patient is aware of the referral and agrees to be contacted by South Eastern Private Hospital *

Specify other symptom/s *

Specify other suspected sleep disorder/s *

Specify other relevant medical condition/s *

Request for *

Initial diagnostic sleep study (# 12203)Repeat diagnostic sleep study (# 12208)CPAP implementation sleep study (# 12204)CPAP treatment review sleep study (# 12205)BiPAP/O2 titration sleep study (# 12207)Split diagnostic and CPAP titration sleep studyMandibular advancement splint sleep studyReferral for follow-up consult with Sleep Physician

Specify Physician (optional)

Clinical history (optional)

GP direct referral questionnaires

Please complete the two questionnaires below to ensure the patient has a high probability for significant symptomatic obstructive sleep apnoea.

Epworth Sleepiness Scale - Patient self-report tool

Please circle only one number per scenario: (0 = never, 1 = slightly, 2 = moderately, 3 = highly).

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times (last few months). Even if you have not done some of these things recently, try to work out how they would have affected you.

Patient score - Epworth Sleepiness Scale

Total must be 8 or higher to be eligible for direct referral for initial sleep study, followed by Sleep Physician consultation. For patients with values < 8, they will be referred for a Sleep Physician consultation first.

OSA50 - Patient self-report tool

Please circle yes or no.

Is your waist circumference more than 102cms (male) or more than 88cms (female)? *

YesNo

Has your snoring ever bothered other people? *

YesNo

Has anyone noticed that you stop breathing during your sleep? *

YesNo

Are you over 50 years old? *

YesNo

Patient score - OSA 50 *

Total must be 5 or higher to be eligible for direct referral for initial sleep study, followed by Sleep Physician consultation. For patients with values 5, they will be referred for a Sleep Physician consultation first.

Referral period *

3 months12 monthsIndefinite

Upload referral letter, if needed

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Submission of an online referral does not does not automatically constitute acceptance of the referral. We will contact your patient, and you will be advised of the outcome.

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