southernsleep
______________________Sleep Study Date

1138a South Road, Clovelly Park SA 5042
PO Box 370, Melrose Park SA 5039
E-mail: info@southernsleep.com.au
HealthLink EDI: sthsleep
Tel: (08) 8373 4430
Fax: (08) 8177 0689
Mobile: 0405 096 996
www.southernsleep.com.au
 Referral

  Dr Dimitar Sajkov 		  Refer to A/Prof Dimitar Sajkov and/or associates 
       (next available appointment with any associated specialist)

TEST REQUESTED:
  Diagnostic Sleep Study					  Sleep Specialist Consultation	
  Other: ________________________________

PATIENT DETAILS

Patient Name: _________________________________________________	Sex (circle):     M   /    F
Address: _________________________________________________________________________________
DOB: _________________ 	e-mail: _____________________	Fund Name:  ______________________
Tel: __________________	Mobile: ____________________	Fund Number: _____________________
Medicare No: ________________________________________	M/C Exp date:    ____________________

 Private Patient 		 DVA Gold Card Holder 		 

Clinical Details (see over):                                       ESS = …. /24               OSA50 = ….  /10  ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Study Date: _______________________________________	Follow-up Date: _______________________

EXTRA MEASUREMENTS OR OBSERVATIONS (eg TCCo2, video monitoring)		Yes / No
SPECIAL ASSISTANCE (e.g. transferring to bed, turning during the night)		Yes / No
Does the patient suffer from any communicable or infectious disease?			Yes / No  
If yes to either of the above please specify: _______________________________________________________
Referring Doctor
Doctor’s Name: __________________________________________	Provider No: _________________________________________
Address: _______________________________________________________________________________________________________
Tel: ____________________________________________________	Fax:  _______________________________________________
Signature: ______________________________________________	Date:  ______________________________________________

Specialist approval of the test prior to consultation (if ESS > 8/24 and OSA50 > 5/10)
Specialist Signature: _____________________________________	Date:  ______________________________________________

REFERRING DOCTOR TO COMPLETE QUESTIONNAIRES WITH PATIENT
Note: ESS must be ≥8 AND OSA50 must be ≥5 to meet criteria for a Medicare funded diagnostic PSG without a Respiratory/Sleep Specialist review prior. If criteria are not met, the patient will need to be seen by a Sleep Specialist first.

EPWORTH SLEEPINESS SCALE     
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times.  Even if you have not done some of these things recently try to work out how they would have affected you.  
Please circle one response (the most appropriate for you) for each question below.
                                                                                          (chance of dozing)             
	
Situation	Never	Slight 	Moderate	High	
Sitting and reading	0	1	2	3	
Watching TV	0	1	2	3	
Sitting, inactive in a public place (e.g. a theatre or a 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	/24	

OSA50 Questionnaire
	If ‘yes’, circle	
Obesity: Waist circumference (measured at umbilicus) - Males >102cm (pant size 40) or Females >88cm (pant size 16)?	3	
Snoring: Has your snoring ever bothered other people?	3	
Apneas: Has anyone noticed that you stop breathing during your sleep?	2	
50: Are you aged 50 years or over?	2	

TOTAL SCORE	
        /10	

Triage Criteria for Ambulatory (Home) Sleep Studies

Criteria for home-based ambulatory study
•	High pre-test probability of OSA, exclusive of other suspected sleep disorders
•	Absence of significant comorbidities, excluding hypertension, well controlled diabetes, well controlled depression
•	Ability to arrange transport to Southern Sleep at 1138a South Road, Clovelly Park and to arrange return of the equipment the following day
•	No cognitive impairment
•	Aged 18-75 years	Conditions unsuitable for ambulatory study
o	Neuropsychological impairment (intellectual disability, major communication issues)
o	Severe physical disability with inadequate carer attendance
o	Home environment unsuitable: noise, partner/family interactions, distance from sleep lab
o	Discretionary: symptoms or results of former testing do not equate with clinical impression, request for second opinion, medico-legal consequences
o	Parasomnia/seizure disorder/narcolepsy/PLMS suspected
o	Transcutaneous CO2 monitoring indicated (type 2 respiratory failure suspected) e.g. neuromuscular disease, severe COPD or restrictive lung disease, hypoxia or hypercapnia at rest, home oxygen therapy, suspected obesity hypoventilation syndrome, significant CVD, chronic narcotic use
o	Video monitoring or extended EEG/EMG required	
PATIENTS UNSUITABLE FOR AMBULATORY DIAGNOSTIC TESTING
WILL REQUIRE AN IN-HOSPITAL SLEEP STUDY	
Priority Patients will be given high priority for testing if any of the following apply:
•	Commercial driver or high-risk occupation
•	Reported near miss or actual motor vehicle or industrial accidents due to sleepiness
•	ESS > 14
•	Uncontrolled HT, unstable cardiovascular disease or AF
•	Pregnancy