Sleep Study Referral		Referral Date: <TodaysDate>	

Service Requested:   Home diagnostic sleep study program. Bulk-billed Level 2 PSG.

Referral to:
Dr. Archit Chawla, Dr. Veenu Mubarak, Dr. Dugal Smith, Dr. Geoff Williams

Rise Sleep Health 
34/137 Scottsdale Drive
Phone:1300 911 755
Fax:     07 3112 5025			Referring General Practitioner:
<DrName> 
<Practice>
<UsrAddress>

Phone: <UsrPhone>    Fax: <UsrFax>
Provider No.: <DrProviderNo>
	
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Patient details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
BMI (mandatory)   <BMI>kg/m
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Title:	<PtTitle>
Medicare No:          <PtMCNo>
Ref No:                        <PtMCLine>
		Contact Address:		
<PtAddress>
<PtStreet>
<PtCity> <PtPostcode>
	      
Phone: <PtPhoneH>
Work:  <PtPhoneWk>	
Mobile: <PtPhoneMob>		
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Epworth Sleepiness Scale (ESS) -  (New Medicare requirement)

In the following situations, how likely is the patient to doze off or fall asleep, in contrast to just feeling tired? Use the following scale to choose one most appropriate number for each situation. Score out of 24 and the referral requires a minimum of 8 to proceed. (0 - Never, 1 - Slight, 2 - Moderate, 3 - High)

Sitting and Reading	<Sitting and Reading (0,1,2,3)>	
Watching TV 	<Watching TV (0,1,2,3)>	
Sitting inactive in a public place	<Sitting inactive in a public place (0,1,2,3)>	
Being a passenger in a car for one hour	<Being a passenger in a car for one hour (0,1,2,3)>	
Lying down in the afternoon	<Lying down in the afternoon (0,1,2,3)>	
Sitting and Talking to someone	<Sitting and Talking to someone (0,1,2,3)>	
Sitting quietly after lunch (without alcohol)	<Sitting quietly after lunch (without alcohol) (0,1,2,3)>	
Stopping for a few minutes in traffic	<Stopping for a few minutes in traffic (0,1,2,3)>	
Score	__________ Out of 24	

STOPBANG - Score out of 8 and the referral requires a minimum of 3 to proceed, each "Yes" below is one point. (New medicare requirement)

S - Does the patient Snore?	<Snore?>	
T - Does the patient feel Tired during the day time?	<Tired>	
O -Anyone Observed the patient to havestopped breathing during sleep?	<Observed>	
P - Is the patient being treated for HighBlood Pressure?	<High BP>	
B - Is the patients BMI greater than 35?	<BMI>35>	
A - Is the patient Age 50 or older?	<Age>50>	
N - Is the patient’s Neck circumference greater than 40cm?	<Neck>40cm>	
G - Is the patient’s Gender male?	<Gender-Male>	
Score	__________ Out of 8	

Reason for Referral: <Reason for referral>