Online Referral for GPs

Bulk Billing is available for Sleep Studies and Respiratory Function Tests

Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Sleep Study
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Field is required!
* Please complete the ESS and STOP-BANG questionnaires. Only patients with ESS ≥ 8 and STOP – BANG score ≥ 3 qualify for a direct referral as per the Medicare requirements.
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Field is required!
Respiratory Function Tests
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Field is required!

Requesting Doctor

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Signature
Upload
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EPWORTH SLEEPINESS SCALE (ESS)

Use the scale on the right to choose the most
appropriate number for each situation
Field is required!
Field is required!
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
Field is required!
Field is required!

SITUATION

CHANCE OF DOZING (0 – 3)

Sitting and reading
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Watching TV
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Sitting, inactive in a public place (e.g. a theatre or a meeting)
Field is required!
Field is required!
–
+
Field is required!
Field is required!
As a passenger in a car for an hour without a break
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Lying down to rest in the afternoon when circumstances
permit
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Sitting and talking to someone
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Sitting quietly after a lunch without alcohol
Field is required!
Field is required!
–
+
Field is required!
Field is required!
In a car, while stopped for a few minutes in the traffic
Field is required!
Field is required!
–
+
Field is required!
Field is required!
Write down total score
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Field is required!
ESS score need to be ≥ 8 to qualify for a Bulk Billed Sleep Study
Field is required!
Field is required!
Field is required!
Field is required!

STOP-BANG QUESTIONNAIRE

Do you SNORE loudly?
Field is required!
Field is required!
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Do you often feel TIRED, fatigued, or sleepy during the daytime?
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Field is required!
Field is required!
Field is required!
Has anyone OBSERVED you stop breathing or choke or gasp for air
during your sleep?
Field is required!
Field is required!
Field is required!
Field is required!
Do you have or are you being treated for high blood PRESSURE?
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Field is required!
Field is required!
Field is required!
BMI more than 35 kg per m2?
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Field is required!
Field is required!
Field is required!
Age over 50 years old?
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Field is required!
Field is required!
Field is required!
Neck circumference >40 cm?
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Field is required!
Field is required!
Field is required!
Gender: Male?
Field is required!
Field is required!
Field is required!
Field is required!
Write down total YES score
Field is required!
Field is required!
STOP – BANG score need to be ≥ 3 to qualify for a Bulk Billed Sleep Study
Field is required!
Field is required!
Field is required!
Field is required!
Submit

Online Referral