BSL 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 o f ≥ 8 or;

• Score ≥ 3 points on the STOP-Bang + have an ESS of ≥ 8

If unsure complete referral and send to Bendigo Sleep Lab who will contact referrer and/or patient as required to manage appropriate clinical pathway.

Enter Full Name* This field is required.

First Name

Last Name

Enter Email* This field is required.

example@example.com

Mobile Number* This field is required.

Please enter a valid phone number.

OSA 50* This field is required.*Waist measurements need to be done at the level of the umbilicus (belly button).

Calculation of Points - OSA 50

STOP-Bang* This field is required.*Enter height and weight if BMI unknown ^Measured around the Adams apple

Calculation of Points - Stop-Bang

Height (cm)* This field is required.*Enter your height in cm

Weight (kg)* This field is required.*Enter your weight in kg

Epworth Sleepiness Scale (ESS)* This field is required.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’ve affected you.

Calculation of Points - ESS