Medicare Eligibility Test

Patient Information

Surname*

Given Name*

Date of Birth (required)*

Sex*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Medicare No*

Email*

Phone*

Private health insurance

Indications, Symptoms and Health Comorbidities*

For a Medicare subsidised sleep study a patient must score 8 or more on the following questions below.

How likely are you to fall asleep if you are sitting & reading?*

How likely are you to fall asleep if you are watching television?*

How likely are you to fall asleep if you are sitting inactive in a public place (i.e theatre or meeting)*

How likely are you to fall asleep lying down in the afternoon, when circumstances permit?*

How likely are you to fall asleep if sitting and talking to someone?*

How likely are you to fall asleep sitting quietly after lunch without alcohol?*

How likely are you to fall asleep as a passenger in a car for an hour without a break?*

How likely are you to fall asleep in a car as a driver stopped for a few minutes in traffic?*

Other clinically relevant notes.

Please Specify