Sleep Study Referral		Referral Date: Miscellaneous.Date	

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

Referral to:
Dr. Archit Chawla, Dr. Veenu Mubarak, Dr. Himanshu Garg, Dr. Geoff Williams

Rise Sleep Health 
34/137 Scottsdale Drive
Phone:1300 911 755
Fax:     07 3112 5025			Referring General Practitioner:
Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number  
	
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Patient details:
Name:	Patient Demographics.First Name> Patient Demographics.Surname
Date of Birth:	Patient Demographics.DOB
BMI (mandatory)   BMI/m
Preferred Name/s:	Patient Demographics.First Name
Sex:	Patient Demographics.Gender
Title:	Patient Demographics.Title
Medicare No:          Patient Demographics.Medicare Number>
		Contact Address:		
<Patient Demographics.Address

Phone:	Patient Demographics.Phone (Home)>
Work:	Patient Demographics.Phone (Work)
Mobile:	Patient Demographics.Phone (Mobile)	
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Epworth Sleepiness Scale (ESS) -  (Mandatory 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	
Watching TV 	Watching TV	
Sitting inactive in a public place	Sitting inactive	
Being a passenger in a car for one hour	passenger in a car	
Lying down in the afternoon	Lying down	
Sitting and Talking to someone	Sitting and Talking	
Sitting quietly after lunch (without alcohol)	Sitting quietly	
StoppingStopping for a few minutes in traffic	Stopping	
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. (Mandatory 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?	Observe	
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