Sleep Apnea Assessment

Please print and take this referral form to your Doctor who needs to add your medical history, any recently prescribed medications and practice details. Download the form here: Sleep Apnea Form

Sleep Disorder Questionaire

Berlin Questionaire

Request for Referral;

HOME SLEEP STUDY REQUIRES THE FOLLOWING


Both OSA and ESS must be completed to qualify for a Medicare Rebate for the Home sleep study


  EPWORTH SLEEPINESS SCALE (ESS)      


  How likely are you to doze off or fall asleep in the following situations. This refers to your usual way of life in recent times.          


  Even if you haven’t done some of these things recently try to work out how they would have affected you.       


  Use the following scale to choose the most appropriate number for each situation:       

  0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing       


  It is important that you answer each question as best you can.


  Patient must score 8 and over or more.       



 OSA 50 Screening Questionnaire     


  Patient must score 5 or more.