ROCKHAMPTON 
Please fax referral to: (07) 3569 4342
Or email to: support@breathersm.com.au
Medical Objects search: Daniel Judge, Breathe or Sleep
Provider No: 521551RK
Breathe Sleep Medicine will contact your patient with
the next available appointment

PATIENT DETAILS:
Title: <PtTitle>	Name: <PtFullName>	Date of Birth: <PtDoB>	
Phone No: <PtPhoneMob>	
Email Address: <PtEmail>	Medicare: <PtMedicare>	

REQUIRED:
PLEASE CHOOSE OPTION 1 OR OPTION 2

OPTION 1		
<Op1> Physician Consultation (referral includes sleep study if indicated)		
No further information required. Go to Referring Doctor’s details.
                     OR		
OPTION 2		
<Op2> Diagnostic sleep study without physician review.		
For Option 2, Medicare rules require that A and B must be completed:		
<Op2a> A. Epworth Sleepiness Scale score of 8 or more
	                 AND		
<Op2b> B. OSA 50 score of 5 or more OR STOP-Bang score of 3 or more
	(Scores on back)		

CLINICAL NOTES:
<CN>	

REFERRING DOCTOR’S DETAILS
Name: <DrName>	Practice: <Prac>	
Address: <DrAddress>	Provider No: <RefProvNo>	
Signature:	Date: <TodaysDate>	

Breathe Respiratory and Sleep Medicine | Dr Daniel Judge MBBS BSc MPhil FRACP
Ph: 07 4057 3900 Fax: 07 3569 4342   
Suite 2A Flecker House, 3-5 Upward St, Cairns QLD 4870

OSA 50 SCREENING QUESTIONNAIRE
	If yes, SCORE	
Obesity:
Waist circumference:
Male >102cm or Females >88cm	3	
Snoring:
Has your snoring ever bothered other people?	3	
Apnoeas:
Has anyone noticed that you stop breathing during your sleep?	2	
Age:
Are you aged of 50 years or over?	2	
Total Score:	<OSAScore>/10	

STOP-BANG SLEEP APNOEA QUESTIONNAIRE
STOP		
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?	<St1>	
Do you often feel TIRED, fatigued, or sleepy during the daytime?	<St2>	
Has anyone OBSERVED you stop breathing during your sleep?	<St3>	
Do you have or are you being treated for high blood PRESSURE?	<St4>	
BANG		
BMI more than 35kg/m2	<Ba1>	
AGE over 50 years old? 	<Ba2>	
NECK circumference > 16 inches (40cm)?	<Ba3>	
GENDER: Male?	<Ba4>	
Total Score:	<StBaScore>	

High risk of OSA: Yes 5 - 8 
Intermediate risk of OSA: Yes 3-4 
Low Risk of OSA: Yes 0 – 2

EPWORTH SLEEPINESS SCALE
Use the following scale to choose the most appropriate number for each situation
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

Situation	Chance of Dozing 
(0-3)	
Sitting and reading	<ES1>	
Watching TV	<ES2>	
Sitting, inactive in a public place(e.g. a theatre or a meeting)	<ES3>	
As a passenger in a car for an hour with a break	<ES4>	
Lying down to rest in the afternoon when circumstances permit	<ES5>	
Sitting and talking to someone	<ES6>	
Sitting quietly after a lunch without alcohol	<ES7>	
In a car, while stopped for a few minutes in the traffic	<ES8>