cpap

N E T W O R K

1300 27 27 63

Home Sleep Study Referral Form

Email to hss@cpapnetwork.com.au or fax/email directly to one of our convenient

CPAP Network locations. Our Sleep Apnoea Consultants will contact the patient to book an appointment for their Home Sleep Study.

Patient details

First name							Surname							
																		
Address																	
																		
Suburb/town										State					Postcode		
														
Commercial drivers licence (if applicable)	◯ Yes		◯ No		
Gender									◯ Male   ◯ Female		
Height	Weight	BMI	Neck circumference		
	m			kg					kg/m2					cm		

Phone			Mobile	
							
Email							
						
Date of birth						
/	/	(DD/MM/YYYY) (must be 18 years or older to be bulk-billed)	
Medicare/DVA Number	Reference number   Expiry date	

◯	Medicare Bulk-Billed (no charge to patient)

◯	Private (a $350 charge will apply)

Referring doctor’s details

Name							Signature				
												
Surgery name												
												
Address							Date				
								/	/			
Suburb/town				State		Postcode	Please stamp if available		

												
Phone		Fax										
												
Provider number												
												
Email												

Comorbidities

◯ Atrial fibrillation	◯ Diabetes	◯ Stroke/TIA	◯ Depression	
◯ Hypertension	◯ COPD	◯ Cardiac failure	◯ Other		

Results required

◯	Standard   ◯ Urgent

◯	Email (secure message)   ◯ Fax   ◯ Hard copy

Please complete either the STOP-BANG Questionnaire OR the OSA 50 Screening Questionnaire AND the Epworth Sleepiness Scale on behalf of patient

STOP-BANG Questionnaire

Do you snore loudly?	◯ Yes

Do you often feel tired, fatigued, or sleepy during the daytime? ◯ Yes Has anyone observed you stop breathing during your sleep? ◯ Yes Do you have or are you being treated for high blood pressure? ◯ Yes

Do you have a BMI of more than 35kg/m2?	◯ Yes		
Are you over the age of 50?	◯ Yes		
Is your neck circumference greater then 40cm?	◯ Yes		
Gender – are you male?	◯ Yes		
Total score (must be ≥ 3 to meet Medicare criteria)			

◯	No

◯	No

◯	No

◯	No

◯	No

◯	No

◯	No

◯	No

OR OSA 50 Screening Questionnaire

Waist circumference:

Male > 102cm, Female > 88cm

Has your snoring ever bothered other people?

Has anyone noticed you stop breathing during your sleep?

Are you aged 50 years or over?

Total score (must be > 5 to meet Medicare criteria)

If YES, score:

3

3

2

2

Epworth Sleepiness Scale (ESS)

0 – Would never doze off	1 – Slight chance of dozing off	2 – Moderate chance of dozing off	3 – High chance of dozing off

Sitting and reading	◯ 0	◯ 1	◯ 2	◯ 3			
Watching TV	◯ 0	◯ 1	◯ 2	◯ 3			
Sitting, inactive in a public place (e.g. waiting room, theatre or meeting)	◯ 0	◯ 1	◯ 2	◯ 3			
As a passenger in a car for an hour without a break	◯ 0	◯ 1	◯ 2	◯ 3	cnetwork		
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 traffic	◯ 0	◯ 1	◯ 2	◯ 3			
Total score (must be > 8 to meet Medicare criteria)					cnetwork_coreplus@argus.net.au		

All personal information in this referral form will be handled and dealt with in accordance with our Privacy Policy (a copy of which can be obtained from our website, www.cpapnetwork.com.au)

V.03.26 fillable

cpap

N E T W O R K

CPAP Network clinics conveniently located at:

 Lilydale	 Boronia	 Heidelberg	
Lilydale Sleep Apnoea Centre	Melbourne Eastern Pharmacy	Heidelberg Healthcare Pharmacy	
283 Main Street	157 Scoresby Road	119 Burgundy Street	
P: 9739 4174 F: 9739 5672	P: 9839 3377 F: 9839 3378	P: 9458 1244 F: 9458 3320	
E: lilydale@cpapnetwork.com.au	E: boronia@cpapnetwork.com.au	E: heidelberg@cpapnetwork.com.au	

 Cranbourne	 Mornington	 Balwyn North	
Cranbourne Sleep Apnoea Centre	Mornington Sleep Apnoea Centre	Greythorn Amcal Pharmacy	
4/78 High Street (enter via Bakewell St)	Shop 3/193 Main Street	297-301 Doncaster Road	
P: 5998 8998 F: 5996 8660	P: 5990 5888 F: 5990 5880	P: 9857 7363 F: 9857 9244	
E: cranbourne@cpapnetwork.com.au	E: mornington@cpapnetwork.com.au	E: balwyn@cpapnetwork.com.au	

 Belgrave	 Clayton	 Preston	
Belgrave Community Pharmacy	Clayton Sleep Apnoea Centre	Preston Sleep Apnoea Centre	
1639 Burwood Highway	1344 Centre Rd	348 High Street	
P: 9754 2001 F: 9752 6012	P: 9546 7014 F: 9739 5672	P: 8470 5200 F: 8470 5299	
E: belgrave@cpapnetwork.com.au	E: clayton@cpapnetwork.com.au	E: preston@cpapnetwork.com.au	

1300 27 27 63	cpapnetwork.com.au