SLEEP DISORDER REFERRAL – Sleep Naturally / 

Dr Benjamin Ng	Dr Geoff Williams 	Dr Alvin Tung	
Respiratory and Sleep Medicine	Respiratory and Sleep Medicine 	Respiratory and Sleep Medicine

Referral Date:	____ / ____ / ____
						
Patient Details	DOB:  __ /__ / ___		Referring Doctor		
Name				Name		
Address				Surgery		
Contact Phone				Provider #		
Email				Telephone		
Medicare						
Height/Weight				Signature		

Service Requested			 		 

   Diagnosis of Sleep Apnoea and Management Advice (Test) 			
  CPAP Treatment Introduction			Review of CPAP 	Treatment	 MAS (Mandibular Advancement Splint)	

TO BE COMPLETED BY THE GP, OR SLEEP CLINICAL STAFF
STOP BANG Questionnaire, Symptoms	
(Answering YES to 4 or more questions qualifies for a Bulk Billed Study, otherwise a consultation with the Sleep Physician is required)
Symptoms					
S noring (enough to be heard through closed doors)	Yes	/ 	No
T iredness (daytime Sleepiness)				Yes	/ 	No
O bserved (witnessed apnea)				Yes	/ 	No
P ressure (Blood Pressure)				Yes	/ 	No
B MI > 35				Yes	/ 	No
A ge > 50				Yes	/ 	No
N eck Size > 40cm				Yes	/ 	No
G ender      Male				Yes	/  	No			
Total Score (Stop Bang)	_______		
Yes 5 – 8 High Risk of OSA   	Yes 3 – 4 Intermediate Risk of OSA	Yes 0 – 2 Low Risk of OSA
						
Waking up, Choking, gasping	Yes	/ 	No	
Memory Loss	Yes	/ 	No	
Nocturia, frequency    ______		

PLEASE DETAIL ANY HEALTH CONDITIONS:  ie.  Heart, Cholesterol, Depression, Diabetes, etc.  
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Epworth Sleepiness Score (ESS)      0 = would never doze   1 = slight chance of dozing   2 = moderate chance of dozing   3 = high chance of dozing 

Q1____ 	Q2___ 	Q3___ 	Q4___ 	Q5___ 	Q6___ 	Q7___ 	Q8___ 	Total ____
Reading	TV	Public	Passenger	Rest	Chatting	After Lunch	Driving
(ESS must score above 8 to qualify for a Bulk Billed Study, otherwise a consultation with the Sleep Physician is required) 
	 
Please fax this referral to 02 8076 7639 or Call 02 9760 1256
bookings@westsleep.com.au  www.westsleep.com.au