M R S S

Melbourne Respiratory & Sleep Services

Online Referral

If you prefer to use a hard copy please find our referral forms below.

Sleep study request form
Respiratory Laboratory Consultation
Patient Details

Tests Required

**Please complete ESS and OSA 50 questionnaires on the reverse side. For Medicare subsidised sleep study prior to or without sleep physician consultation following criteria must be met. ESS >=8 and OSA 50>=5


Epworth Sleepiness Scale (ESS)

How likely are you to doze off 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 haven’t done some of these things recently, try to work out how they would have affected you.

Use the following scale:
0 = Would never doze  
1 = Slight chance of dozing  
2 = Moderate chance of dozing  
3 = High chance of dozing

Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991 Dec;14(6):540-5.


OSA-50 Screening Questionnaire

Please answer the following questions. A score of 5 or above (out of 10) may indicate a risk of Obstructive Sleep Apnoea.

  • Obesity = Yes (3), No (0)
  • Snoring = Yes (3), No (0)
  • Apnoeas = Yes (2), No (0)
  • Age 50 or Over = Yes (2), No (0)

For direct referral for sleep studies (At home or in LAB): ESS ≥ 8 & OSA-50 ≥ 5 (both conditions must be satisfied).

IMPORTANT — Please see detailed respiratory test preparation instructions and medication withholding requirements below.
Products To Be Avoided Prior To Testing Routine Testing Bronchial Provocation Testing
Short acting bronchodilator
(Ventolin, Bricanyl, Atrovent, Asmol)		 6 Hours 8 Hours
LAMA
(Spiriva, Genuair, Seebri, Incruse, Anoro)		 12 Hours 24 Hours
LABA
(Serevent, Foradile, Oxis, Onbrez, Anoro)		 24 Hours 24 Hours
Combination steroid/LABA
(Seretide, Symbicort, Flutiform, Ellipta)		 24 Hours 24 Hours
Antihistamine
(Zyrtec, Telfast, Claratyne etc.)		 N/A 72 Hours
Caffeine N/A Day of Test
Theophylline
(Nuelin, Theodur)		 N/A 24 Hours

⚠ Do not stop any medication that is essential for your safety without medical advice.

Referring Practitioner Details

Please include an email address if you would like to receive a copy of this referral.

Enter the name of any GP, specialist or healthcare provider who should receive a copy of the consultation report or investigation results.

Contact Info:

  • Phone: (03) 9459 0555
  • Fax:

    03 9455 0786

  • Email: reception@mrss1.com.au
  • Heidelberg:

    226 Burgundy St, Heidelberg VIC 3084

  • Doncaster:

    Advara HeartCare , Centre for cardiology, Unit 1/1008 Doncaster Rd, Doncaster East VIC 3109