Online Referrals for GPS

Bulk Billing is Available for Sleep Studies and Respiratory Function Tests

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Field is required!
Field is required!
Field is required!
Field is required!
Sleep Study
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* Please complete the ESS and STOP-BANG questionnaires. Only patients with ESS ≥ 8 and STOP - BANG score ≥ 4 qualify for a direct referral as per the Medicare requirements.
Respiratory Function Tests
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Requesting Doctor

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Signature
Upload
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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
-
+
Field is required!
Watching TV
-
+
Field is required!
Sitting, inactive in a public place (e.g. a theatre or a meeting)
-
+
Field is required!
As a passenger in a car for an hour without a break
-
+
Field is required!
Lying down to rest in the afternoon when circumstances
permit
-
+
Field is required!
Sitting and talking to someone
-
+
Field is required!
Sitting quietly after a lunch without alcohol
-
+
Field is required!
In a car, while stopped for a few minutes in the traffic
-
+
Field is required!
Write down total score
Field is required!

STOP-BANG QUESTIONNAIRE

Do you SNORE loudly?
Field is required!
Do you often feel TIRED, fatigued, or sleepy during the daytime?
Field is required!
Has anyone OBSERVED you stop breathing or choke or gasp for air
during your sleep?
Field is required!
Do you have or are you being treated for high blood PRESSURE?
Field is required!
BMI more than 35 kg per m2?
Field is required!
Age over 50 years old?
Field is required!
Neck circumference >40 cm?
Field is required!
Gender: Male?
Field is required!
Write down total YES score
Field is required!

PLEASE AVOID THE FOLLOWING PRIOR TO TESTING:

(Scroll to right to see more)
TIME TO AVOID PRIOR TO TEST
Medication Class Generic Name Respiratory Function Testing Bronchial Provocation Testing
SABA Ventolin, Bricanyl, Atrovent, Asmol 6 hours 8 hours
ICS Alvesco, Flixotide, Pulmicort, Qvar, Arnuity 24 hours 24 hours
LAMA Spiriva, Bretaris, Seebri, Incruse 12 hours 24 hours
LABA Serevent, Foradile,Oxis, Onbrez 24 hours 24 hours
LAMA/LABA Spiolto, Ultibro, Brimica, Anoro 24 hours 24 hours
LABA/ICS Seretide, Symbicort, Flutiform, Breo 24 hours 24 hours
LAMA/LABA/ICS Trelegy 24 hours 24 hours
Theophylline Nuelin, Theodur NA 24 hours
Antihistamine Zyrtec, Telfast, Claratyne NA 72 hours
Caffeine Coffee, tea, soft drinks, energy drinks NA Day of Test

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