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Online Sleep Study Referral (For Doctors)
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Online Sleep Study Referral (For Doctors)
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*
" indicates required fields
Patients Name
*
Email
*
Phone
*
Doctor Name
*
Doctors Provider No
*
Doctors Surgery
*
Date of birth
*
DD slash MM slash YYYY
Medicare No
*
Ref No
*
Reason for Referral
ESS - Test 1 of 2
Have you ever felt sleepy, or think you may get sleepy in the future, doing the following:
You can not proceed to Test 2 unless Sleepiness is 8 or more.
Qualify for a Bulk Billed sleep study if your score is higher than 8.
Never
0pt
Slight
1pt
Moderate
2pts
High
3pts
Sitting and reading
Never
Slight
Moderate
High
Watching TV
Never
Slight
Moderate
High
Sitting inactive in a public place
Never
Slight
Moderate
High
Being a passenger in a car for an hour
Never
Slight
Moderate
High
Lying down in the afternoon
Never
Slight
Moderate
High
Sitting and talking to someone
Never
Slight
Moderate
High
Sitting quietly after lunch (without alcohol)
Never
Slight
Moderate
High
Stopping for a few minutes in traffic
Never
Slight
Moderate
High
This field is hidden when viewing the form
ESS Score
Score
0
/24
You can not proceed the STOPBANG unless ESS is 8 or more. Qualify for a Bulk Billed sleep study if your score is 8 or higher.
We’re sorry to say you do not qualify for a bulk-billed sleep test. You can, however, get a private sleep study for $360, or you can retake the test.
Your ESS is 8 or more. You may now proceed to the STOPBANG.
STOPBANG - Test 2 of 2
Please select which are applicable.
Qualify for a Bulk Billed sleep study if your STOPBANG score is 3 or more.
Snore
Yes
S
- Do you
S
nore?
Tired
Yes
T
- Do you feel
T
ired during the day time?
Observed
Yes
O
- Has anyone
O
bserved you stop breathing during sleep?
Pressure
Yes
P
- Are you being treated for High Blood
P
ressure
Body
Yes
B
- Is your
B
ody Mass Index greater than 35?
Age
Yes
A
- Are you
A
ge 50 or older?
Neck
Yes
N
- Is your
N
eck circumference greater than 40cm?
Gender
Yes
G
- Is your
G
ender male?
This field is hidden when viewing the form
STOPBANG Score
Score
/8
Qualify for a Bulk Billed sleep study if your score is 3 or more.
Your STOPBANG score is 3 or more, you qualify for a bulk-billed sleep study as long as you haven't had one in the last 12 months.
Your patient qualifies for a bulk billed sleep study!
Please send the signed referral to Rise Sleep Health at referrals@risesleephealth.com.au. The referral will be sent to your patient and you will be able to download it and upload it to your medical software.
Maybe consider a private Sleep Study
We’re sorry but your patient does not qualify for a bulk-billed sleep test. You can, however, get a private sleep study or your patient can retake the test.
Epworth Sleepiness Scale (ESS)
Sitting and reading
Watching TV
Sitting inactive in a public place
Being a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (without alcohol)
Stopping for a few minutes in traffic
STOPBANG
S
- Do you
S
nore?
T
- Do you feel
T
ired during the day time?
O
- Has anyone
O
bserved you stop breathing during sleep?
P
- Are you being treated for High Blood
P
ressure
B
- Is your
B
ody Mass Index greater than 35?
A
- Are you
A
ge 50 or older?
N
- Is your
N
eck circumference greater than 40cm?
G
- Is your
G
ender male?
Get a Rise Sleep pre-filled referral form
A Sleep Study Referral will be emailed to your patient. You can download the form and upload it to your medical software. Please send the referral to referrals@risesleephealth.com.au Your patients' referral will not be shared with third parties.
Email Results
Please email me my sleep-health score to provide to my GP for referral to Rise.
Rise Contact
Please contact me to discuss my sleep health and organise a sleep study
Phone
This field is for validation purposes and should be left unchanged.
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