Respiratory and Sleep Medicine Referral form	

Mater Medical Centre | Westside Private | John Flynn
Suite 18 & 22 Level 6, 293 Vulture Street, South Brisbane 4101
Suite 303 Level 3, 32 Morrow Street, Taringa 4068 
Suite 6E, Fred McKay House, 42 Inland Drive, Tugun 4224
T: 3123 5350 F: 3123 5338 E: reception@respirologist.com.au

		         We will contact the patient for an appointment

PATIENT NAME	
	
DATE OF BIRTH	

<<Patient Demographics:Full Name>>	
	
<<Patient Demographics:DOB>>	

PHONE NUMBER	
	
GENDER	

<<Patient Demographics:Phone (Mobile)>>	
	
<<Patient Demographics:Gender>>	

ADDRESS	
	
MEDICARE/DVA  NUMBER	

<<Patient Demographics:Full Address>>	
	
<<Patient Demographics:Medicare Number>>
<<Patient Demographics:DVA Number>>	

RESPIRATORY LAB
	
Full (complex) respiratory function tests	

Locations:	
	
Mater	
	
Westside	
	
JFH	

(e.g. for suspected COPD, Interstitial lung disease, dyspnoea of unknown cause)
We perform spirometry + bronchodilator reversibility (if indicated by presence of airflow obstruction) + gas transfer (diffusion). If there is the suggestion of restriction or severe airflow obstruction, static lung volumes will be performed if available.	

	
Spirometry + exhaled nitric oxide	

Locations:	
	
Mater	
	
Westside	
	
JFH	

(e.g. for suspected asthma or monitoring progress of asthma)
We perform spirometry + bronchodilator reversibility + fractional exhaled nitric oxide to measure for airway allergy.	

	
Mannitol bronchoprovocation	

Locations:	
	
Mater	
	
Westside	
	
JFH	

Where asthma is suspected but baseline spirometry is normal.	

	
Cardiopulmonary exercise test*	

Locations:	
Westside Only	

*Indicates can only be requested by Respiratory Physicians due to Medicare restrications.	

CONSULTATIONS
	
Dr Michael Fanning FRACP (Respiratory & Sleep Physician)	

Locations:	
	
Mater	
	
Westside	

	
Dr Matt Fanning FRACP (Respiratory & Sleep Physician)	

Locations:	
	
Mater	
	
Westside	
	
JFH	

	
Dr Masa Kudo FRACP (Respiratory, Sleep & General Physician)	

Locations:	
	
Westside	
	
Mater	

	
Dr Kirryn Williams FRACP (Respiratory, Sleep & General Physician)	

Locations:	
	
JFH	

	
Dr Chinthaka Samaranayake FRACP (Respiratory & Sleep Physician)	

Locations:	
	
JFH	

CLINICAL NOTES

	

		SLEEP LAB
Diagnostic study:	
	
Ambulatory	
	
Laboratory	

(Mandatory to complete Steps 1-5 below if referrer is not a Respiratory/Sleep Physician)

Treatment study:	
	
CPAP*	
	
NIV*	
	
ASV*	
	
MAS*	
	
+TcCO2*	

Vigilance study:	
	
MSLT*	
	
MWT*	

*Indicates can only be requeste by Respiratory or Sleep Physician due to Medicare restrictions.	

STEP 1:EPWORTH SLEEPINESS SCALE (ESS)

How likely is the patient to doze off or fall asleep in the following situations:

0=would never fall asleep                                  2=moderate chance of falling asleep
1=slight chance of falling asleep                        3=high chance of falling asleep
Sitting and reading
Watching TV
Sitting inactive in a public place (theatre, meeting, etc)
As a passenger in a car for an hour without a break
In a car, while stopped for a few minutes in traffic
Lying down to rest in the afternoon
Sitting quietly after lunch without alcohol
Sitting and talking to someone
TOTAL SCORE (>= 8 required for direct PSG referral; >10 abnormal)	
__/3
__/3
__/3
__/3
__/3
__/3
__/3
__/3
__/24	

•		

STEP 2: OSA50 QUESTIONNAIRE FOR RISK OF OSA

If yes, score:
Obesity        Waist circumference >102 cm for males or >88 cm for females
Snoring        Has your snoring ever bothered other people?
Apnoeas      Has anyone noticed that you stop breathing during your sleep?
50                Are you aged 50 years or over?
                    TOTAL SCORE(>=5 required for direct PSG referral)	
3
3
2
2
__	

•		

STEP 3: ELIGIBILITY FOR DIRECT REFERRAL MEDICARE SUBSIDISED

DIAGNOSTIC SLEEP STUDY

Yes	

	
No	

	
Patient has qualified if ESS>=8 AND OSA50>=5.
Please send referral. We will contact the patient.

OPTIONS:
	
Sleep physician consultation-recommended as >50% of patients 	

with OSA do not meet new Medicare criteria	

	
Non-Medicare diagnostic sleep study-please send referral and we 	

will contact patient with options	

	

•		

STEP 4: SYMPTOMS - TICK IF ANY APPLY

Snoring	
	
Witnessed apnoeas/gasping/choking	
	
Daytime lethargy/sleepiness	

	
Cognitive/memory issues	
	
Headaches	
	
Restless sleep	
	
Irritability	
	
Insomnia	

•		

STEP 5: PATIENT PRESENTATION - TICK IF ANY APPLY

*Indicates an attended (in-lab) study may be required
	
Cardiac co-morbidity*	
	
Neuromuscular disease*	
	
Suspected additional sleep disorder*	

	
Type II diabetes mellitus	
	
Neurologic disease*	
	
Previous failed study*	
	
Nocturia	

	
Hypothyroidism*	
	
Hypertension	
	
Respiratory disease*	
	
Insomnia*	

	
Patient prefers lab study*	
	
Body position required*	
	
Suspected central sleep apnoea*	

	
Suspected narcolepsy*	
	
Unsuitable for home environment*	

	

REFERRING DOCTOR DETAILS Results will be sent via Medical Objects by default. If this is not possible, results will be sent by post/fax to the address below. 

Name:	
<<Doctor:Name>>	
Signature:	
	
Date:	
<<Miscellaneous:Date>>	

Provide Number:	
<<Doctor:Provider Number>>	
Address:	
<<Doctor:Full Address>>	

cc: