Online Referral Form

Online Referral Form

MID NORTH COAST SLEEP CLINIC
PATIENT NAME*

First NameLast Name
DATE OF BIRTH*
Enter DD/MM/YYYY format
Email*
example@example.com
Mobile Phone Number*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
REFERRING PATIENT FOR:*

HOME SLEEP STUDYCPAP TRIALCPAP PRESSURE REVIEW WITH OXIMETRY
MEDICAL HISTORY

DIABETES TYPE 2OBESITYASTHMACOPDATRIAL FIBRILLATIONCARDIAC FAILUREHYPERTENSIONSTROKE/TIA
OTHER CO-MORBIDITIES
EPWORTH SLEEPINESS SCALE How likely are you to fall asleep in the following situations? Please score each activity using the following guide: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance 3 = high chance of dozing ACTIVITY SCORE
Sitting and Reading*
Watching television*
Sitting inactive in public place (e.g. meeting/theatre)*
Travelling as passenger in car on long trip - more than 1 hr*
Lying down to rest in the afternoon (if able)*
Sitting talking to someone*
Sitting quietly after lunch (without alcohol)*
In a car, while stopped in traffic*
TOTAL SCORE .../24
To qualify for a Home Sleep Study the patient should score: ≥ 8/24
STOP BANG QUESTIONNAIRE
Snoring: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?*

YESNo
Tired: Do you often feel tired, fatigued or sleepy during daytime?*

YESNo
Observed: Has anyone observe you stopping breathing during your sleep?*

YESNo
Blood pressure: Do you have or are you being treated for high blood pressure?*

YESNo
BMI: Is your BMI more than 35kg/m2?*

YESNo
Age: Are you over 50 years old?*

YESNo
Neck Circumference: Is your neck circumference greater than 40cm?*

YESNo
Gender:*

MALEFEMALERATHER NOT SAY
To qualify for a Home Sleep Study patient should answer YES to 3 or more questions.
REFERRING DOCTOR INFORMATION
REFERRING DOCTOR'S NAME*
PROVIDER NUMBER*
PRACTICE NAME*
PRACTICE PHONE NUMBER AND EMAIL*
REFERRAL DATE*

DayMonthYear
Date
Should be Empty:

Online Referral Form

EPWORTH SLEEPINESS SCALE How likely are you to fall asleep in the following situations? Please score each activity using the following guide: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance 3 = high chance of dozing ACTIVITY SCORE

STOP BANG QUESTIONNAIRE

REFERRING DOCTOR INFORMATION