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REFERRAL FORM

Referral Form

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    Sleep Disordered Breathing Evaluation. This form is only to be filled out by a heathcare professional.

    PATIENT

    CLINICAL INFORMATION

    CLINICAL PROFILE

    Please enter a value between 100 and 300.

    Please enter a value between 20 and 200.

    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:

    Sitting and reading

    Situation:

    Watching TV

    Situation:

    Sitting, inactive in a public place e.g. theatre or meeting)

    Situation:

    As a passenger in a car for an hour without a break

    Situation:

    Lying down to rest in the afternoon when circumstances permit

    Situation:

    Sitting and talking to someone

    Situation:

    Sitting quietly after lunch without alcohol

    Situation:

    In a car, while stopped for a few minutes in traffic

    Please enter a value between 0 and 24.

    REFERRING PHYSICIAN