QUEENSLAND SLEEP
ADULT STUDY ASSESSMENT REFERRAL
Tel: 1800 717 566	E: sa@qsdu.com.au
Locations: Brisbane, Sunshine Coast, Cairns, Lismore, Rockhampton, Townsville

Name	DOB
Address	Mobile

Please fax referral to 07 3217 2523
Medical Objects: search “sleep” or Provider number SQ41010017D Qld Sleep will contact your patient with the next available appointment

Test Requested

STEP 1
Comments: OR

Diagnostic Sleep Investigation.(Proceed to and complete 4,5,6,7 and 8).

STEP 2

CPAP Titration

MAS/MRD Titration

Body Position Modiﬁcation Study

Comments:

Sleep Physician consultation MUST be seletected in addition to studies in STEP 2 and will only be booked if clinically indicated and with patient consent.

STEP 3	Sleep Physician Consultation (Proceed to and complete step 8)

STEP 4	OSA50 Questionnaire	If “yes” circle	Patient score:

Is waist circumference >102cm if male or >88cm if female? Has the patient’s snoring ever bothered other people?
Has anyone reported apneas during the patient’s sleep? Is the patient over 50 years of age?

3
3
2
2
Total _____________

STEP 5	Epworth Sleepiness Scale	(Rate 0-3 to indicate chance of dozing) 0-Unlikly 3-Likely
Sitting and Reading	0	1	2	3	
Watching TV	0	1	2	3	
Passenger in car trip	0	1	2	3	
Sitting and talking to someone	0	1	2	3	
Sitting inactive in public (meeting or theatre)	0	1	2	3	
Lying down in the afternoon when able	0	1	2	3	
Sitting after lunch without alcohol	0	1	2	3	
In a car stopped in trafﬁc for a few minutes	0	1	2	3	Total _______________	
STEP 6	OSA50 Score must be >5 AND Epworth Sleepiness score must be >8 to meet criteria for a Medicare funded diagnostic sleep investigation. If the criteria are not met,
Refer to Step 3 and request a sleep physician consult.	OSA50 Score	ESS Score

STEP 7	Does the patient have any of the following (please tick all that apply)

Unexplained sleepiness (adequate sleep hygiene and environment)
Active cardiac disease / arrhythmia Possible movement disorder (no RLS) Possible sleep hypoventilation Possible parasomnia
STEP 8	Referring Doctor’s Details:

Acromegaly or thyroid disease Possible central sleep apnea Neurological Issues
Unsuitable home environment (note reason)
Reason:   	

Name:     	

Address:		 Signature:   	

Provider no:   	 Date:   	

www.queenslandsleep.com.au

Rev. No. V4.0 Effective June 2021