Home-Based Sleep Study Request Form

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RSDC Ferntree Gully
719 Burwood Hwy, Ferntree Gully VIC 3156

RSDC Knox
Knox Private Hospital, 262 Mountain Hwy, Wantirna VIC 3152

RSDC Balwyn
55 Whitehorse Rd, Deepdene VIC 3103

Patient details:

Symptoms:

Snoring
Witnessed Apnoea
Excessive Daytime Sleepiness
Waking Unrefreshed
Nocturia
Morning headache
High STOP-BANG

Other Medical Conditions:

Neurologic / Stroke / TIA
Cardiac Failure / AF / AMI
Diabetes Mellitus
Hypertension
Obesity
COPD
Psychiatric Disorder
Preoperative Assessment
Other

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