Patient Portal
(03) 4141 4239

Sleep Study Referral

Please complete and submit the below form.

Sleep Study Referral

Both OSA 50 and ESS scores must be complete to qualify for a Medicare rebated Home Sleep Study (Medicare item 12250)

ESS Questionnaire (How likely are you to doze off (fall asleep) in the following situations?
Patient must score 8 or more.
Sitting and reading
Watching Television
Sitting inactive, in a public space
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
As a passenger in a car for an hour without a break
In a car, while stopping for a few minutes in traffic
OSA-50 Screening Questionnaire, Waist circumference (Measure at the level of the umbilicus)
Male >102cm I Females >88cm
Has your snoring bothered other people?
OSA-50 Screening Questionnaire Questions 2
Has anyone noticed you stop breathing during your sleep?
Are you aged 50 years or over?
Symptoms and Medical Conditions

For a referral to be valid, please ensure the following details are completed and SIGNED

Gippsland Specialist Clinic is a multi-specialty practice with a team of passionate medical professionals who are committed to providing you with the best possible care and experience.

Phone

(03) 4141 4239

Hours

Mon-Fri 9am - 5pm

Social

Our Services

About

Copyright © 2024, Gippsland Specialist Clinic