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 |
c  Consultation with a Specialist Physician | Respiratory Function Tests (Bulk Billed)
Sleep Study (Bulk Billed) | c  Spirometry & Transfer Factor
c  Hospital based sleep study (privately insured patients) | c  FeNO and Spirometry
c  Home based sleep study* | c  Plethysmographic lung volumes

*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.

c  Mannitol provocation test (Additional fees apply)

| c  Maximal Respiratory Pressures
| c  6 minute walk test
| c  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:History List>>

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)