Peninsula Sleep Clinic
www.peninsulasleepclinic.com.au	Ph: 9451 0522 Fx: 9451 1422
reception@peninsulasleepclinic.com.au
Forest Central Business Park
Suite 3, Level 2, Building 1,
49 Frenchs Forest Road East,
Frenchs Forest NSW 2086
	
<Peninsula Sleep Clinic eReferral>Peninsula Sleep Clinic eReferral
Referral Request
<1. Please select the required procedure. ^NATA/Australasian Sleep Association accredited services> procedure
Patient details		
First name: <PtFirstName>	Last name: <PtSurname>	
Gender: <PtSex>	Date of birth: <PtDoB>	
Phone: <PtPhoneH>	Mobile: <PtPhoneMob>	
Procedure Requested ^NATA/Australasian Sleep Association accredited services	
GP/Specialist Referral<GP/SPECIALIST REFERRAL>	

<Diagnostic Sleep Study^ (PTO screening criteria)> Diagnostic Sleep Study^ (PTO screening criteria)	

<Dental Device Sleep Study^> Dental Device Sleep Study^
Type: <Type of Dental Device Sleep Study>	

<Positional Device Sleep Study^>Positional Device Sleep Study
Type: <Type of Positional Device Sleep Study>	

Home Sleep Screening:<Home Sleep Screening:>	

<Home Sleep Study (PTO screening criteria)>Home Sleep Study (PTO screening criteria)	

<ApneaLink (Flow, Oximetry, Effort) *no Medicare rebate*>ApneaLink (Flow, Oximetry, Effort) *no Medicare rebate*	

	Sleep Physician Referral<SLEEP PHYSICIAN REFERRAL>	

<CPAP Titration^>CPAP Titration^	

<CPAP Review^>CPAP Review^
Reason: <Reason for CPAP Review:>
Instruction: <Instruction for CPAP Review>	

<Non-Invasive Ventilation>Non-Invasive Ventilation
Instruction: <Instruction for Non-Invasive Ventilation:>	

Oxygen <Oxygen Titration> Titration or <Oxygen Review> Review
Instruction: <Instruction for Oxygen Titration or Review>	

<Maintenance of Wakefulness Test^>Maintenance of Wakefulness Test^	

<Multiple Sleep Latency Test^>Multiple Sleep Latency Test^	

Any additional instructions and/or relevant clinical information:
<Any additional instructions and/or relevant clinical information:>

 Consultation Request: Peninsula Respiratory Group - Sleep/Respiratory Specialists<2. Consultation Request: Peninsula Respiratory Group - Sleep/Respiratory Specialists>	
<Dr Keith Burgess> Dr Keith Burgess		
<Dr Stanley Braude> Dr Stanley Braude	

<Dr Kate Barclay> Dr Kate Barclay	
<Dr Linda Seeto> Dr Linda Seeto	

<Dr Philip Lee> Dr Philip Lee	
<Dr Patricia Hullah> Dr Patricia Hullah	

<First Available> First available	

	

Referring Doctor		
Name: <DrFirstName> <DrSurname>	Provider #: <DrProviderNo>     Date: <TodaysDate>	
Doctor's Signature: <***DOCTOR'S SIGNATURE*** (Please type your name as signature equivalent)>	Clinic Address:<UsrAddress>	
Report cc: <Report cc (if required)>	
	
 Additional Screening Information <3. Additional Screening Information>	
<Suspected respiratory failure> Suspected respiratory failure	
<Suspected parasomnia disorder> Suspected parasomnia disorder	

<Neuromuscular disorder> Neuromuscular disorder	
<Neuromuscular disorder> Suspected seizure disorder	

<Advanced respiratory disease> Advanced respiratory disease. Type: <Type of Advanced respiratory disease>	
<Heart failure> Heart failure	

<Cognitive impairment> Cognitive impairment	
<Suspected positon related disorder (e.g. supine sleep apnoea)> Suspected positon related disorder (e.g. supine sleep apnoea)	

<Failed home sleep study> Failed home sleep study	
<Physical disability or inadequate care attendance> Physical disability or inadequate care attendance	

<Unsuitable home environment for testing> Unsuitable home environment for testing	

A<PLEASE COMPLETE THE QUESTIONNAIRES ON PAGE 2 IF REQUESTING A DIAGNOSTIC SLEEP STUDY OR UNATTENDED SLEEP STUDY>

Patient Screening Questionnaires:
Please complete the following screening questionnaires with your patient. It is now a Medicare requirement that for a patient to qualify for an overnight sleep study without seeing a Sleep Physician they need to:
•	Score ≥ 5 points on the OSA 50 + have an ESS of ≥ 8 or; 
•	Score ≥ 4 points on the STOP-Bang + have an ESS of ≥ 8
If unsure complete referral and send to Peninsula Sleep Clinic who will contact referrer and/or patient as required to manage appropriate clinical pathway. 

OSA 50	If yes, add SCORE	
Obesity	Waist Circumference* 
Male > 102cm
Female > 88cm	3	
Snoring	Has your snoring ever bothered people?	3	
Apnoeas	Has anyone noticed that you stop breathing during your sleep?	2	
50	Are you aged 50 years or over?	2	
*Waist measurements need to be done at the level of the umbilicus (belly button).                       Total	ENTER SCORE	

STOP-Bang	If yes, add SCORE	
Snoring	Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?	1	
Tired	Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?	1	
Observed	Has anyone Observed you Stop Breathing or Choking
/Gasping during your sleep?	1	
Pressure	Do you have or are being treated for High Blood Pressure?	1	
Body Mass Index*	Height: ENTER Weight: ENTER BMI: ENTER  Is BMI ≥35/kg/m2?	1	
Age	Are you aged 50 years or over?	1	
Neck Size^	Male, is your shirt collar 17 inches / 43cm or larger?
Female, is your shirt collar 16 inches / 41cm or larger?	1	
Gender	Are you male?	1	
*Enter height and weight if BMI unknown     ^Measured around the Adams apple                       Total 	ENTER SCORE	
       
Epworth Sleepiness Scale (ESS)	If yes, add SCORE	
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 haven’t done some of these things recently try to work out how they would have affected you.	Never	
Slight
	
Moderate
	High	
Sitting and reading	0	1	2	3	
Watching T.V.	0	1	2	3	
Sitting, inactive in a public place (e.g. theatre, 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 lunch without alcohol	0	1	2	3	
In a car, while stopped for a few minutes in the traffic	0	1	2	3	
Total 	ENTER SCORE