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Physician:

Physician Signature:

Date:

PATIENT REFERRAL FORM

** PLEASE AFFIX PATIENT LABEL IF AVAILABLE **

Name:

Address:

PHONE NUMBERS

Home: Work:

Cell:

Date of Birth: DD / MM / YY

Reason for Referral:

Assess for OSA

Other (symptoms):

REQUESTED SERVICE

Please note the Home Sleep Study is FREE of charge

Home Sleep Study

CPAP Trial

Sleep well, feel well.

Snore Shop Charlottetown161 St. Peters RoadCharlottetown, PE C1A 5P6Tel: 902-367-6374Fax: 902-367-6376pei@thesnoreshop.ca

Snore Shop Summerside61 Central StreetSummerside, PE C1N 3L2Tel: 902-367-6374Fax: 902-367-6376pei@thesnoreshop.ca

WWW.THESNORESHOP.CA

STOP-BANG QUESTIONNAIREA tool to screen for Obstructive Sleep Apnea

SNORINGDo you snore loudly (louder than talking or loud enough to be heard through closed doors)? YES NO

TIREDDo you often feel tired, fatigued or sleepy during the daytime? YES NO

OBSERVEDHas anyone observed you stop breathing during your sleep? YES NO

BLOOD PRESSUREDo you have or are you being treated for high blood pressure? YES NO

BMIBMI more than 35kg/m2? YES NO

AGEAge over 50 years old? YES NO

NECK CIRCUMFERENCENeck circumference greater than 40cm / 16”? YES NO

GENDERGender - Male? YES NO

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STOP-Bang Scoring Model

Chung F., et al

"YES" to three or more items indicates a high risk of OSA.

"YES" to less than three items indicates a low risk of OSA.