Manse Medical Referral Form

Manse Medical's Referral Form

Patient Details

First Name *

Surname *

Date of Birth *

Phone Number *

Email Address *

Address *

Street Address *

Suburb or City *

State *

Postcode *

Services

~ If referring for sleep services, please complete the STOP-Bang Questionnaire and Epworth Sleepiness Scale at the end of this referral. ~

Symptoms and Sleep History

Please tick all sleep symptoms and history that apply.

Comorbidities and Medical History

Clinical Notes

Please enter any notes in the space below.

Or please attach notes below.

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Referrer Details

Name of Physician *

Clinic Email Address *

Provider No. *

Clinic Phone Number *

Date *

Clinic Address *

Street address *

Suburb or City *

State *

Postcode *

Signature *

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STOP-Bang Questionnaire

Please tick all that apply. Each tick equals one score.

Does the patient snore loudly?

Does the patient often feel tired, fatigued, or sleepy during the daytime?

Has anyone observed the patient stop breathing during sleep?

Does the patient have or is being treated for high blood pressure?

Does the patient have a BMI of more than 35?

Is the patient aged over 50 years old?

Does the patient have a neck circumference (shirt size) more than 40cm / 16 inches?

Is the patient genetically male?

Total score for STOP-Bang Questionnaire

Epworth Sleepiness Scale (ESS)

How likely is the patient to doze off? Tick one box from each row.

Total Score for Epworth Sleepiness Scale

Manse Services

And we're done! This referral will be emailed to you, your referrer and Manse Medical. A team member will contact you within two business days to assist with booking an appointment.

I consent for Manse Medical to send marketing communication that may be relevant to me such as clinic updates, promotions and service information.I consent for Manse Medical to use the data provided in this questionnaire in an unidentifiable manner for research and development purposes.