家庭医生在线转诊表 | Sleep and Lung Care

家庭医生在线转诊

持有效转诊信，肺功能检查和符合条件的居家睡眠监测由 Medicare 全额支付（bulk billed）。门诊费用以及医院睡眠监测的任何费用另行收取；前台会在预约前向您说明适用的费用。

此表格供转诊医生使用。已有转诊信的患者请使用上传转诊信。

本转诊表供转诊医生使用，为英文版。

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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