Please print out and have doctor/GP complete, and then return to Rockingham CPAP by:
email at [email protected], fax on 08 9593 6266,
or in person at Shop 23 Warnbro Centre, 206 Warnbro Sound Ave, Warnbro WA 6169
Rockingham CPAP will contact you to make an appointment

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cpap

Phone 08 6186 6636
Fax 08 9593 6266
[email protected]

Dr Cheng Long Lu

FRACP MBBS BMedSci (Melb) PGCertClinical Ultrasound
Respiratory and Sleep Physician
Patient Details
Sleep Services Required
Home Based Sleep Study (Level 2) Sleep Physician Consultation
CPAP Trial Sleep Physician (Telehealth)
CPAP Support Positional Therapy
Screening Questionnaries
OSA50
 Yes No
Obese Is waist circumference >102cm for males or >88cm for females? 3 0
Snoring Is snoring disruptive to anyone? 3 0
Apnoeas Has anyone observed you stopping breathing during your sleep? 2 0
50 Years Are you over 50 years in age? 2 0
Total score: /10
------------------------------------------------------- OR -------------------------------------------------------
STOP-BANG
STOP
 Yes No
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? 1 0
Do you often feel TIRED, fatigued, or sleepy during daytime? 1 0
Has anyone OBSERVED you stop breathing during your sleep? 1 0
Do you have or are you being treated for high blood PRESSURE? 1 0
BANG
 Yes No
BMI more that 35? 1 0
AGE over 50 years old? 1 0
NECK circumference > 40cm (16 inches)? 1 0
GENDER: Male? 1 0
Total score: /8
------------------------------------------------------- AND -------------------------------------------------------
Epworth Sleepiness Score
Sitting and reading
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Watching TV
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Sitting quietly in a public place
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
In a car stopped in traffic
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Sitting and talking to
someone
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Sitting quietly after lunch without alcohol
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Lying down to rest in
the afternoon
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
As a passenger in a car for an hour without a break
0. Never doze
1. Slight chance of dozing
2. Moderate chance of dozing
3. High chance of dozing
Total score: /24
Note: Medicare rebate for home based sleep studies requires an OSA50 score of greater than/or equal 5, or a STOP-BANG score of greater than/or equal 3, and an ESS of greater than/or equal 8
Clinical Details
Diabetes Obesity Daytime Somnolence
Hypertension Mobility Impairment Commercial Driver
Atrial Fibrillation Restless Sleep Heavy Machine Operator
Heart Failure Morning Headaches Pacemaker
Stroke/TIA COPD Clinical History (attach note)
Other
 
For Doctor

All Medicare subsidised home based sleep studies must meet the criteria of the OSA50 or STOP-BANG, and ESS in accordance with Medicare item 12250.
cpap

Phone 08 6186 6636
Fax 08 9593 6266
[email protected]

Shop 23/206 Warnbro Sound Ave
Warnbro WA 6169

Rockingham CPAP is proudly partnered with Warnbro Pharmacy
warnbropharmacy