WA SLEEP
ADULT STUDY ASSESSMENT REFERRAL
Tel: 1300 65 1234 E: reception@wasleep.com.au
HEAD OFFICE: SJOG Level 1, Suite 102, 25 McCourt St, Subiaco WA 6008
Name		 Email 	

Return referral via: 1300 65 1234 or email at reception@wasleep.com.au

D.O.B.		 Medicare/Ref#	 Pvt. Health Fund/No. 	 Address 				 Mobile 	
Test Requested (Please tick and/or circle) Location:  Subiaco  Murdoch  Mandurah  Kalgoorlie  Geraldton
STEP 1	 Diagnostic Sleep Investigation + Management (Home-based / In Lab)
 CPAP titration, Bilevel titration, NSR, MAS, or Split Study  DVA Approved Equipment Supply for Eligible Patients

MSLT/MWT Study CPAP trial/support
Others 	

 TcCO2
 Urgent
Bilevel IPAP: 	 EPAP: 	

STEP 2	OSA50 Questionnaire	If “yes” circle		
	Is waist circumference >102cm if male or >88cm if female?	3		
	Has the patient’s snoring ever bothered other people?	3		
	Has anyone reported apnoeas during the patient’s sleep?	2		
	Is the patient over 50 years of age?	2	Total 		

STEP 3	Epworth Sleepiness Scale	(Rate 0-3 to indicate chance of dozing) 0-Unlikely 3-Likely
Sitting and Reading	0	1	2	3		
Watching TV	0	1	2	3		
Passenger in car trip	0	1	2	3		
Sitting and talking to someone	0	1	2	3		
Sitting inactive in public (meeting or theatre)	0	1	2	3		
Lying down in the afternoon when able	0	1	2	3		
Sitting after lunch without alcohol	0	1	2	3		
In a car stopped in traffic for a few minutes	0	1	2	3	Total 		

environment)

STEP 4		Does the patient have any of the following  Unexplained sleepiness (adequate sleep hygiene and  Active cardiac disease / arrhythmia
 Possible movement disorder (no RLS).
 Possible sleep hypoventilation  Possible parasomnia

Acromegaly or thyroid disease Possible central sleep apnoea Neurological issues
Unsuitable home environment BMI > 40

www.wasleep.com.au

Rev. No. V3 Effective March 2024

Clinical Details: 	
STEP 5	Referring Doctor Details:
Name:		 Clinic/Practice Name: 	 Practice/Address: 		 Provider no: 	
Signature: 		Date: 	

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