First Name *

Surname *

Date of Birth *

Email Address *

Phone Number *

Clinical HistoryPlease complete Epworth Sleepiness Scale (ESS) and STOP BANG questionnaires on next page

Type of Study

Diagnostic Sleep StudyDiagnostic Study with Dental SplintHome Sleep StudyWard Sleep Study

Sleep Physician Review?

with Dr Andrew Scott

Specialist Referral Only

CPAP titration (initial)CPAP review studyMSLT/ MWT studyBievel study

Referring Doctor Details

Name *

Provider Number *

Clinic Details

Practice Email

Signature *

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Epworth Sleepiness Scale (ESS)

All patients referred for testing must have an Epworth Sleepiness Scale completed.

For a Medicare subsidised sleep study a patient must score 8 or more.

How likely are you to doze off in the following situations?

For a Medicare subsidised sleep study a patient must score 3 or more

STOP BANG Total Score

This form will be submitted via email to Thoracic and Sleep Group Queensland. A copy will also be sent to the patient email address provided above.