Sleep and Lung Care Referral Form

Service required
Note:- To select the boxes, highlight the check box and press X to select the service/s 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	c  Plethysmographic Lung Volumes	
c  Home based sleep study*	c  Bronchial Provocation Test (Mannitol)	
*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.
Please see next page for questionnaires.	c  Maximal Respiratory Pressures	
	c  6 minute walk test	
	c  FeNO & Spirometry	
Clinical Notes:

	
Comments:	Reason for Referral

Patient
Name:	Patient Demographics.Full Name		DOB:	Patient Demographics.DOB		Gender:	Patient Demographics.Gender	

Telephone:	h)  Patient Demographics.Phone (Home)		Mobile Number:	m)  Patient Demographics.Phone (Mobile)	

Address:	Patient Demographics.Address 
Patient Demographics.Suburb  Patient Demographics.Postcode	

Medicare No:	Patient Demographics.Medicare Number		DVA No:	Patient Demographics.DVA Number	

Health Fund:	Patient Demographics.Health Fund Name		Fund Member No:	Patient Demographics.Health Fund Member Number	
Referrer

Name:	Treating Doctor.Name		Provider No:	Treating Doctor.Provider Number	

Address:	Practice.Address

Telephone:	Practice.Phone		Fax:	Practice.Fax	

Email:	 	

Signature:			Date:	Miscellaneous.Date	

Please fax to: (039454 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 m2?	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)		

PLEASE AVOID THE FOLLOWING PRIOR TO LUNG FUNCTION TESTING:

	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