Referral Missing Information

Please Provide Your Information Below

First Name*

Last Name*

Date of Birth*

Email*

Phone Number*

Medicare Number*

Address (Unit Number, Street & Suburb)*

State*

Postcode*

Your responses will assist the Sleep Physician in assessing your sleep-related symptoms and risk factors.

Epworth sleepiness scale (ESS)

The Epworth Sleepiness Scale assesses your level of daytime sleepiness in everyday situations.

Please indicate how likely you are to doze off or fall asleep in the following situations, rather than simply feeling tired. Base your answers on your usual way of life in recent times. Even if you have not experienced some of these situations recently, try to estimate how they would affect you.

How likely are you to doze off in these situation	Never	Slight	Moderate	High
Sitting and reading	0	1	2	3
Watching television	0	1	2	3
Sitting inactive in a public place (e.g. a theatre or meeting)	0	1	2	3
As a passenger in a car for an hour without a break	0	1	2	3
Lying down to rest in the afternoon when circumstances permit	0	1	2	3
Sitting and talking to someone	0	1	2	3
Sitting quietly after a lunch without alcohol	0	1	2	3
In a car, while stopped for a few minutes in the traffic	0	1	2	3
Total score: 0

The STOP-BANG Questionnaire is a validated screening tool used to identify the risk of obstructive sleep apnoea (OSA). It includes questions relating to snoring, daytime tiredness, observed breathing pauses during sleep, blood pressure, body mass index (BMI), age, neck circumference, and gender. Higher scores indicate an increased risk of sleep apnoea.

STOP-BANG Questionnaire

Please answer Yes or No to the following questions	Yes	No
Do you snore loudly?	1	0
Do you often feel tired, fatigued, or sleepy during the daytime?	1	0
Has anyone observed you stop breathing during your sleep?	1	0
Do you have or are you being treated for high blood pressure?	1	0
Are you obese/very overweight - BMI more than 35 kg/m²?	1	0
Age over 50 years old?	1	0
Neck circumference greater than: 43cm (male) or 41cm (female)	1	0
Are you male?	1	0
Total score: 0

The OSA50 Questionnaire is a screening tool used to assess the risk of obstructive sleep apnoea (OSA). It includes questions relating to snoring, daytime sleepiness, witnessed breathing pauses during sleep, waist circumference, and age. Higher scores indicate an increased risk of sleep apnoea.

OSA 50 Screening Questionnaire

Please answer Yes or No to the following questions	Yes	No
Waist circumference Male > 120cm or Females > 88cm	3	0
Has your snoring ever bothered other people?	3	0
Has anyone noticed you stop breathing during your sleep?	2	0
Are you aged 50 years or over?	2	0
Total score: 0

Your Results

Epworth Sleepiness Scale (ESS): 0 points

STOP-BANG Questionnaire: N/A

OSA 50 Screening Questionnaire: N/A

Who provided you with the sleep test referral?*

GP Lung and Sleep Specialist

CLM Study Registration Form

Please Provide Your Information Below

Your responses will assist the Sleep Physician in assessing your sleep-related symptoms and risk factors.

Epworth sleepiness scale (ESS)

Total score: 0

STOP-BANG Questionnaire

Total score: 0

OSA 50 Screening Questionnaire

Total score: 0

Your Results

Sleep Test Funding and Testing Preference

Self-fund the sleep test

Pre-assessment with a Sleep Physician

Access our services from 50+ locations across Australia

Subscribe to hear about our latest promotion

Fund raising activities

CPAP & Sleep Health Days

School Chats - Blackfriars Priory School

Stretch for a cause

CLM Study Registration Form

Please Provide Your Information Below

Your responses will assist the Sleep Physician in assessing your sleep-related symptoms and risk factors.

Epworth sleepiness scale (ESS)

Total score: 0

STOP-BANG Questionnaire

Total score: 0

OSA 50 Screening Questionnaire

Total score: 0

Your Results

Sleep Test Funding and Testing Preference

Self-fund the sleep test

Pre-assessment with a Sleep Physician

Access our services from 50+ locations across Australia

Subscribe to hear about our latest promotion

Fund raising activities

CPAP & Sleep Health Days

School Chats - Blackfriars Priory School

Stretch for a cause

Journey to Tomorrow

Sleeping Better, Together Starts Today