WSC_PreAssessment

Sleep Study Pre Assessment - Medicare

Our Sleep Specialist requires the below information to complete the review and scoring of your sleep study.

We ask for your help by completing these questions when you packup your sleep machine.

Patient First Name *

Patient Surname *

Medicare Number (xxxx xxxxx x) *

Medicare Card Patient position No: (number next to patient name) *

Medicare Expiry Date *

Date of Birth *

Patient Height (cm): *

Patient Weight (kgs) : *

Patient Home address *

Street address *Street address line 2

City *

State *

Postcode *

Epworth Sleepiness Scale

The Epworth Sleepiness Scale has been designed to measure a patient’s likely daytime sleepiness. How likely are they to doze off during the day in the following situations? (8 or more for Medicare Approval) 0: None 1: Slight 2: Moderate 3: High

Sitting quietly after lunch - no alcohol *

0123

Stopped in traffic whilst driving a car *

0123

Total ESS (add up the score) /24 *

STOP BANG

Tick all that apply (3 or more for Medicare Approval)

Snoring (1 pt)

Observed stops breathing (1 pt)

Often tired, fatigued, sleepy (1 pt)

High Blood Pressure (1 pt)

BMI over 35kg/m2 (1 pt)

Aged over 50 (1 pt)

Optional: Neck, Male or Female > 40cms (1 pt)

Gender = Male (1 pt)

If neck > 40cms above, Must enter Size in cms:

Total STOP BANG /8 : *

OSA 50

If Stop Bang or ESS doesn’t meet Medicare criteria - enter OSA50 data. Must achieve 8 of 13 for Medicare Approval. Tick all that apply

Snoring bothers others (3 pt)

Observed stops breathing (2 pt)

Age over 50 (2 pts)

Waist - Male > 102cm (3 pt)

Waist - Female > 80cm (3 pt)

Total OSA50 /13

CONTRAINDICATIONS

(Answer Yes or No. If Yes - please provide the details)

Have you previously failed or had an inconclusive unattended sleep study? *

Do you have a high level of anxiety about conducting a sleep study at home? *

Do you have a suitable home environment to conduct this sleep study ? *

Do you have a physical or intellectual disability which will affect the way you are able to conduct the sleep study? If so, do you have adequate carer attendence? *

Do you have any neuromuscular disease ? *

Do you have Heart failure ? *

Have you ever suffered from advanced respiratory disease or respiratory failure? *

Do you have any seizure disorders ? *

Have you or anyone else noticed any unusual sleep behaviors ? *