Free Self-Check

Sleep apnoea check.

This short screening (STOP-BANG + the Epworth Sleepiness Scale) helps identify whether you may be at risk of obstructive sleep apnoea — and whether you may be eligible for a Medicare-rebated home sleep study. If you qualify, you can print a form to take to your GP to sign, then drop it in at Inspire Clinic.

Your details
STOP-BANG questionnaire

Answer Yes or No to each.

S — Do you snore loudly (louder than talking, or heard through a closed door)?
T — Do you often feel tired, fatigued or sleepy during the daytime?
O — Has anyone observed you stop breathing or choking/gasping during sleep?
P — Do you have, or are you being treated for, high blood pressure?
B — Is your BMI more than 35 kg/m²?
A — Are you older than 50 years?
N — Is your neck circumference greater than 40 cm?
G — Is your gender male?
Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in these situations (not just feel tired)?  0 = never · 1 = slight · 2 = moderate · 3 = high chance.

Sitting and reading
Watching television
Sitting inactive in a public place (e.g. a theatre or meeting)
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

Pressing the button shows your result and sends your answers and contact details to Inspire Clinic reception, so we can follow up with you.

We only share your details as set out in our Privacy Policy.
Prefer to talk it through? Call us on 0402 166 415.
Inspire Clinic
Tobruk House, Shop 2, 8 Archer Street, Rockhampton City QLD 4700 · reception@inspireclinic.au · 0402 166 415
Home Sleep Study
Screening & GP Referral

Client details

Name: Date of birth:
Mobile: Email:
Medicare no.: Date completed:

STOP-BANG

Total: / 8

Epworth Sleepiness Scale

Total: / 24

GP / specialist referral

I have reviewed this client, whose clinical history and screening scores are consistent with a risk of obstructive sleep apnoea. I refer them for a Medicare-rebated home-based sleep study (e.g. MBS item 12203). I confirm the client has not had a home-based sleep study in the preceding 12 months.

Referring GP / specialist name:

 		Provider number:

 
Signature:

 		Date:

 
Next step: once signed by your GP, drop this form in at Inspire Clinic, Tobruk House, Shop 2, 8 Archer Street, Rockhampton City QLD 4700, or email a scan to reception@inspireclinic.au. Our team will arrange your home sleep study.
Screening tool only; not a diagnosis. Eligibility and Medicare rebate are determined by the referring practitioner and the sleep clinic.