new patient details & Questionnaire

Please complete the form below, as completely as possible

Title

Name

First Name

Last Name

Gender, as registered with Medicare (to make sure that rebates come back to you)

Preferred Name, Title & Pronouns

Date of Birth

Do you identify as Aboriginal and/or Torres Strait Islander?

Home Address

Suburb, State, Post Code

Postal Address

Mobile Phone

Home Phone

Please include area code

Business Phone

Please include area code

Medicare Number

Medicare Reference Number (located to the left of your name on the card)

Medicare Card Expiry Date

Pension / Concession Card Number

Concession Card Expiry Date

Concession Card Type

Private Health Insurance Fund

Private Health Insurance Membership Number

Veterans Affairs Number

DVA Card Type

Referring Doctor Name

Referring Doctor Address

Referring Doctor Phone Number

Local GP (if different from above) and other key doctors caring for you currently

Have you had a sleep study performed before?

Was your sleep study performed at home or in a facility? Approximately when?

How did you hear about SleepDoctors? e.g. GP / word of mouth / internet search / other.

Please complete this Sleepiness Scale:

How likely are you to doze or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you.

Sitting and reading?

Watching TV?

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

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

Lying down to rest in the afternoon when circumstances permit?

Sitting and talking to someone?

Sitting quietly after lunch without alcohol?

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

ESS Total - please add up the numbers you've scored above.

Patient Registration

new patient details & Questionnaire

Please complete the form below, as completely as possible

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