نموذج الإحالة عبر الإنترنت للأطباء

الإحالة عبر الإنترنت للأطباء

تُغطّى تكلفة فحوصات وظائف الرئة ودراسات النوم المنزلية المؤهلة بالكامل عبر Medicare (bulk billed) مع وجود إحالة سارية. أما رسوم الاستشارة وأي رسوم لدراسات النوم في المستشفى فهي منفصلة؛ وسيشرح لك قسم الاستقبال الرسوم المطبّقة قبل الحجز.

هذا النموذج مخصّص للأطباء المُحيلين. وعلى المرضى الذين لديهم رسالة إحالة بالفعل استخدام ارفع رسالة إحالتك.

نموذج الإحالة هذا مخصص للأطباء المحيلين وهو باللغة الإنجليزية.

Referral priority

URGENT – review within 48 hours requested (suspected lung cancer or lung mass, or rapidly worsening symptoms)

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Withholding times for lung function tests

If you are ordering lung function tests, please give the patient these withholding times — a long-acting inhaler taken that morning may invalidate the pre-bronchodilator result, and the test may have to be repeated. Patients should not stop a medicine they need to stay safe. Printable patient version →

Medicine (examples)	Spirometry, lung volumes, gas transfer, FeNO	Bronchial provocation (mannitol)
Reliever puffers — salbutamol (Ventolin, Asmol, Airomir), terbutaline (Bricanyl)	4–6 hours	8 hours
Ipratropium (Atrovent)	12 hours	12 hours
Twice-daily long-acting and combination inhalers — Seretide, Symbicort, Flutiform, DuoResp, Fostair, Serevent, Oxis	24 hours	36 hours
Once-daily long-acting inhalers — Breo Ellipta, Trelegy, Anoro, Ultibro, Spiolto, Onbrez, Striverdi	36–48 hours	72 hours
Twice-daily triple-therapy inhalers (they contain a long-acting anticholinergic) — Trimbow, Breztri	36–48 hours	72 hours
Long-acting anticholinergics — Spiriva, Seebri, Incruse, Bretaris	36–48 hours	72 hours
Preventer-only inhaled steroid — Flixotide, Pulmicort, Qvar, Alvesco	Take as usual	Skip the morning dose (6 hours)
Montelukast (Singulair)	Take as usual	4 days
Antihistamines — Zyrtec, Claratyne, Telfast, Phenergan	Take as usual	72 hours
Theophylline (Nuelin)	Take as usual	24 hours
Caffeine — coffee, tea, cola, energy drinks, chocolate	Avoid on the morning of the test	24 hours
Smoking or vaping	Not within 1 hour	Not within 1 hour
Alcohol	Not within 8 hours	Not within 8 hours
Vigorous exercise · a large meal	Not within 1 hour · not within 2 hours	Not within 1 hour · not within 2 hours

<div class="salc-prep salc-prep-gp"><h3>Withholding times for lung function tests</h3><p>If you are ordering lung function tests, please give the patient these withholding times — a long-acting inhaler taken that morning may invalidate the pre-bronchodilator result, and the test may have to be repeated. Patients should not stop a medicine they need to stay safe. <a href="https://sleepandlungcare.com.au/respiratory-function-tests/#preparing" target="_blank" rel="noopener">Printable patient version →</a></p><div class="salc-tablewrap"><table class="salc-table"><thead><tr><th>Medicine (examples)</th><th>Spirometry, lung volumes, gas transfer, FeNO</th><th>Bronchial provocation (mannitol)</th></tr></thead><tbody><tr><td>Reliever puffers — salbutamol (Ventolin, Asmol, Airomir), terbutaline (Bricanyl)</td><td>4–6 hours</td><td>8 hours</td></tr><tr><td>Ipratropium (Atrovent)</td><td>12 hours</td><td>12 hours</td></tr><tr><td>Twice-daily long-acting and combination inhalers — Seretide, Symbicort, Flutiform, DuoResp, Fostair, Serevent, Oxis</td><td>24 hours</td><td>36 hours</td></tr><tr><td>Once-daily long-acting inhalers — Breo Ellipta, Trelegy, Anoro, Ultibro, Spiolto, Onbrez, Striverdi</td><td>36–48 hours</td><td>72 hours</td></tr><tr><td>Twice-daily triple-therapy inhalers (they contain a long-acting anticholinergic) — Trimbow, Breztri</td><td>36–48 hours</td><td>72 hours</td></tr><tr><td>Long-acting anticholinergics — Spiriva, Seebri, Incruse, Bretaris</td><td>36–48 hours</td><td>72 hours</td></tr><tr><td>Preventer-only inhaled steroid — Flixotide, Pulmicort, Qvar, Alvesco</td><td>Take as usual</td><td>Skip the morning dose (6 hours)</td></tr><tr><td>Montelukast (Singulair)</td><td>Take as usual</td><td>4 days</td></tr><tr><td>Antihistamines — Zyrtec, Claratyne, Telfast, Phenergan</td><td>Take as usual</td><td>72 hours</td></tr><tr><td>Theophylline (Nuelin)</td><td>Take as usual</td><td>24 hours</td></tr><tr><td>Caffeine — coffee, tea, cola, energy drinks, chocolate</td><td>Avoid on the morning of the test</td><td>24 hours</td></tr><tr><td>Smoking or vaping</td><td>Not within 1 hour</td><td>Not within 1 hour</td></tr><tr><td>Alcohol</td><td>Not within 8 hours</td><td>Not within 8 hours</td></tr><tr><td>Vigorous exercise · a large meal</td><td>Not within 1 hour · not within 2 hours</td><td>Not within 1 hour · not within 2 hours</td></tr></tbody></table></div></div>

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Attach the referral letter (optional)

A PDF, or a photo of each page (JPG, PNG or HEIC). Up to 3 files, 10 MB each. If you attach nothing, this form itself is filed as the referral.

Choose file(s)

Please attach a PDF, JPG, PNG or HEIC file of 10 MB or less.

Requesting Doctor

Please enter your first name.

Please enter your surname.

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Please enter the practice email address.

Signature: please enable JavaScript to sign on screen.

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EPWORTH SLEEPINESS SCALE (ESS)

Use the 0–3 scale to choose the most appropriate number for each situation

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

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SITUATION

CHANCE OF DOZING (0 – 3)

Sitting and reading

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–

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Watching TV

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–

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Sitting, inactive in a public place (e.g. a theatre or a meeting)

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–

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As a passenger in a car for an hour without a break

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–

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Lying down to rest in the afternoon when circumstances permit

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–

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Sitting and talking to someone

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–

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Sitting quietly after a lunch without alcohol

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–

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In a car, while stopped for a few minutes in the traffic

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–

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Write down total score

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For a direct referral based on screening scores, the ESS score needs to be ≥ 8.

<span style="color:#ff0000; font-size:10px;">For a direct referral based on screening scores, the ESS score needs to be ≥ 8.</span>

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STOP-Bang QUESTIONNAIRE

Do you SNORE loudly?

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Yes

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Do you often feel TIRED, fatigued, or sleepy during the daytime?

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Yes

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Has anyone OBSERVED you stop breathing or choke or gasp for air during your sleep?

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Yes

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Do you have or are you being treated for high blood PRESSURE?

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Yes

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BMI more than 35 kg/m²?

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Yes

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Age over 50 years old?

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Yes

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Neck circumference 43 cm or more (men) / 41 cm or more (women)?

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Yes

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Gender: Male?

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Yes

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Write down total YES score

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For the STOP-Bang direct-referral pathway, the STOP-Bang score needs to be ≥ 3 and the ESS score needs to be ≥ 8.

<span style="color:#ff0000; font-size:10px;">For the STOP-Bang direct-referral pathway, the STOP-Bang score needs to be ≥ 3 and the ESS score needs to be ≥ 8.<br />
</span>

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