Dr Richard Nankervis
		FRACP, MBBS, BAppSc, Bsc (Hons)
		Provider #248695XB

Patient Details:
Name:  <<Patient Demographics:Full Name>>                    
DOB:   <<Patient Demographics:DOB>>		Gender: <<Patient Demographics:Gender>>
Adress: <<Patient Demographics:Full Address>>
Phone: <<Patient Demographics:Phone (Mobile)>> / <<Patient Demographics:Phone (Home)>>
Email:  <<Patient Demographics:E-mail>>		Health Fund/DVA: <<Patient Demographics:Health Insurance>> <<Patient Demographics:DVA Number>>

Referring Doctors Details:
Doctors Name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Email: <<Doctor:E-mail>>
CC Dr:
Signature:				Date: <<Miscellaneous:Date>>

Clinical Information:

Diagnostic Study:

	Level 2 Home Study		

	Medicare rebate eligible (see over page)		

	Privately funded (not meeting Medicare Requirements)	

OR

Sleep and Respiratory Physicians ONLY

	In-lab attended study		

	Unsuitable for home study		

	Reason:	

Treatment study:

	CPAP Tritration		

	CPAP review study		

	Dental splint study		

	NIV		

	ASV		

	MWT		

	MSLT	

Symptoms:

	Snoring 

	Witnesses apnoeas 		

	Nocturia	

	Morning headaches		

	Concentration / memory problems		

	Restless legs	

	Dry mouth when waking

	Daytime tiredness/sleepiness		

	Drowsy Driving	

	Choking / gasping awakenings					

Comorbidities: 

	COPD

	Cardiac Arrythmias / Atril Fibrilation		

	Hypertension	

	CCF		

	Movement disorders		

	Parasomnia

	Neurological disease

	Possible central sleep apnoea		

	Type 2 diabetes	

	Ischaemic heart disease		

	Chronic pain			

OSA50 Questionnaire
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	     /10	

Epworth Sleepiness scale (ESS)
Situation	No chance of dozing	Slight chance of dozing	Moderate chance of dozing	High chance of dozing	
Sitting, inactive, in a public place (e.g.in a meeting, theatre, or dinner event)		

0		

1		

2		

3	
As a passenger in a car for an hour or more without stopping for a break		

0		

1		

2		

3	
Lying down to rest when circumstances permit		

0		

1		

2		

3	
Watching TV		

0		

1		

2		

3	
Sitting and reading		

0		

1		

2		

3	
Sitting and talking to someone 		

0		

1		

2		

3	
Sitting quietly after a meal without alcohol 		

0		

1		

2		

3	
In a car, while stopped for a few minutes in traffic or at a light		

0		

1		

2		

3	
TOTAL					
				             
*To meet Medicare funding criteria the OSA50 must be ≥5 AND ESS must be ≥8 (Or be referred by Respiratory/Sleep physician after consultation)