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 (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
Name:		Date of Birth: 	
Address:		
Phone Number:		Mobile Number: 	
Medicare Number:		
Clinical Details:		
Reason for Referral:		

Referrer

Referred By:		
Doctor's Address:		
Doctor's Phone:		Provider Number: 	
Doctor's Email:		Copies To:	
Doctor's Signature:
	
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)