Author: Bassem Dawood

www.sleepandlungcare.com.au                         T: (03) 9422 0077    F: (03) 9454 9339
Argus: sleepandlungcare@argus.net.au
Healthlink ID: SALCCARE

c Epping
Epping Medical Centre
Level 2, Suite 4a
230 Cooper Street
EPPING VIC 3076

c DONCASTER EAST
Suite2, 
1008 Doncaster Rd,
DONCASTER EAST VIC, 3109

c COBURG
John Fawkner Hospital
267 Moreland Road COBURG VIC 3058

c KILMORE
The Kilmore Hospital
Anderson Road
KILMORE VIC 3764

Sleep and Lung Care Referral Form
Service required |
☐ Consultation with a Specialist Physician | Respiratory Function Tests (Bulk Billed)
☐ Hospital based sleep study (privately insured patients) | ☐ Spirometry & Transfer Factor
☐ Home based sleep study* (Bulk Billed) | ☐ FeNO and Spirometry

*Please complete the ESS and STOP-BANG questionnaires. 
Only patients with ESS ≥ 8 and STOP-BANG score ≥ 3 qualify 
for a direct referral as per the Medicare requirements.
Please see next page for questionnaires.

☐ Plethysmographic lung volumes

| ☐ Mannitol provocation test (Additional fees apply)
| ☐ Maximal Respiratory Pressures
| ☐ 6 minute walk test
| ☐ Ambulatory Oxygen Assessment

Clinical Notes: |

Patient
Appointment Date: | [Appointment Date] | Time: | [Time] | Date of Referral: | [Miscellaneous:Date]
Name: | [Patient Demographics:Full Name] | Date of Birth: | [Patient Demographics:DOB]
Address: | [Patient Demographics:Address] |
Phone Number: | [Patient Demographics:Phone (Home)] | Mobile Number: | [Patient Demographics:Phone (Mobile)]
Medicare Number: | [Patient Demographics:Medicare Number]
Clinical Details: | [Clinical Details]
Reason for Referral: | [Reason for Referral]

Referrer

Referred By: | [Doctor:Name]
Doctor's Address: | [Doctor:Address]
Doctor's Phone: | [Doctor:Phone] | Provider Number: | [Doctor:Provider Number]
Doctor's Email: | [Doctor:E-mail] | Copies To: | [Copies To]
Doctor's Signature:

Please fax to: (03) 9454 9339.  Your patient will be contacted within 24 hours.

EPWORTH SLEEPINESS SCALE (ESS)

.

Use the scale on the right to choose the most appropriate number for each situation

0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing

SITUATION | CHANCE OF DOZING (0 - 3)
Sitting and reading |
Watching TV |
Sitting, inactive in a public place (e.g. a theatre or a 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 a lunch without alcohol |
In a car, while stopped for a few minutes in the  traffic |
SCORE TOTAL |

STOP-BANG QUESTIONNAIRE

  
Do you SNORE loudly? | YES      NO
Do you often feel TIRED, fatigued, or sleepy during the daytime? | YES      NO
Has anyone OBSERVED you stop breathing or choke or gasp for air during your sleep? | YES      NO
Do you have or are you being treated for high blood PRESSURE? | YES      NO
BMI more than 35 kg per m^2? | YES      NO
Age over 50 years old? | YES      NO
Neck circumference >40 cm? | YES      NO
Gender: Male? | YES      NO

TOTAL YES SCORE
(High risk of OSA: Yes 5-8) (Intermediate risk of OSA: Yes 3–4) (Low risk of OSA: Yes 0-2)