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	

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ADDRESS:	
	
GENDER	

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PHONE NUMBER	
MEDICARE DETAILS	
	
DVA	

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Medicare: <PtMCNo>
Ref: <PtMCLine> Exp: <PtMCExpiry>	
	
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RESPIRATORY LAB <==RESPIRATORY LAB==>
<Full (complex) respiratory function tests> 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> 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> Mannitol bronchoprovocation
	Locations: ¨ Mater ¨ Westside ¨ JFH
Where asthma is suspected but baseline spirometry is normal.
<Cardiopulmonary exercise test*> Cardiopulmonary exercise test*
	Locations: ¨ Westside only
* Indicates can only be requested by Respiratory Physicians due to Medicare restrictions.	

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
<Clinical Notes>	

		SLEEP LAB <==SLEEP LAB==>	
		Diagnostic study:	<Diagnostic study : Ambulatory> Ambulatory	<Diagnostic study : Laboratory> Laboratory
(Mandatory to complete Steps 1- 5 below if referrer is not a Respiratory/Sleep Physician)
Treatment study:	<Treatment study : CPAP*> CPAP* <Treatment study : NIV*> NIV*  <Treatment study :ASV*> ASV* <Treatment study : MAS*> MAS*	<Treatment study : +TcCO2*> +TcCO2* 
Vigilance study:	<Vigilance study : MSLT*> MSLT* <Vigilance study : MWT*> MWT*
* Indicates can only be requested by Respiratory or Sleep Physician due to Medicare restrictions.

STEP 1: EPWORTH SLEEPINESS SCALE (ESS) <==STEP 1: EPWORTH SLEEPINESS SCALE (ESS)==>
How likely is the patient to doze off or fall asleep in the following situations: <==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>
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	<Sitting and reading:>/3
Watching TV	<Watching TV>/3
Sitting inactive in a public place (theatre, meeting, etc)	<Sitting inactive in a public place (theatre, meeting, etc)>/3
As a passenger in a car for an hour without a break	<As a passenger in a car for an hour without a break>/3
In a car, while stopped for a few minutes in traffic	<In a car, while stopped for a few minutes in traffic>/3
Lying down to rest in the afternoon	<Lying down to rest in the afternoon>/3
Sitting quietly after lunch without alcohol	<Sitting quietly after lunch without alcohol>/3
Sitting and talking to someone	<Sitting and talking to someone>/3
TOTAL SCORE (≥ 8 required for direct PSG referral; > 10 abnormal)	<TOTAL SCORE ( OUT OF 24)>/24	

STEP 2: OSA50 QUESTIONNAIRE FOR RISK OF OSA <==STEP 2: OSA50 QUESTIONNAIRE FOR RISK OF OSA==>
Obesity	<Obesity: Waist circumference 102 cm for males or 88 cm for females (3 points)> Waist circumference >102 cm for males or >88 cm for females	3
Snoring	<Snoring: Has your snoring ever bothered other people? (3 points)> Has your snoring ever bothered other people?	3
Apnoeas	<Apnoeas: Has anyone noticed that you stop breathing during your sleep? (2 points)> Has anyone noticed that you stop breathing during your sleep?	2
50	<50: Are you aged 50 years or over? (2 points)> Are you aged 50 years or over?	2
	TOTAL SCORE (≥ 5 required for direct PSG referral)	<TOTAL SCORE (>= 5 required for direct PSG referral)>	

STEP 3: ELIGIBILITY FOR DIRECT REFERRAL MEDICARE SUBSIDISED <==STEP 3: ELIGIBILITY FOR DIRECT REFERRAL MEDICARE SUBSIDISED==>
DIAGNOSTIC SLEEP STUDY <DIAGNOSTIC SLEEP STUDY>
Yes	<YES: Patient has qualified if ESS >= 8 AND OSA50 >= 5.> Patient has qualified if ESS ≥ 8 AND OSA50 ≥ 5.
	Please send referral. We will contact the patient.
No	OPTIONS: <OTHER OPTIONS>
	<NO: Sleep physician consultation - recommended as >50% of patients with OSA do> Sleep physician consultation - recommended as >50% of patients with OSA do 
	not meet new Medicare criteria
	<NO: Non-Medicare diagnostic sleep study - please fax referral and we will contact patient with options> Sleep physician consultation - recommended as > Non-Medicare diagnostic
	sleep study - please send referral and we will contact patient with options	

STEP 4: SYMPTOMS - TICK IF ANY APPLY <STEP 4: SYMPTOMS - TICK IF ANY APPLY>
<Snoring> Snoring     <Witnessed apnoeas/gasping/choking> Witnessed apnoeas/gasping/choking    <Daytime lethargy/sleepiness> Daytime lethargy/sleepiness
<Cognitive/memory issues> Cognitive/memory issues    <Headaches> Headaches    <Restless sleep> Restless sleep    <Irritability> Irritability    <Insomnia> Insomnia	

STEP 5: PATIENT PRESENTATION - TICK IF ANY APPLY <==STEP 5: PATIENT PRESENTATION - TICK IF ANY APPLY==>
*Indicates an attended (in-lab) study may be required
<Cardiac co-morbidity*> Cardiac co-morbidity*    <Neuromuscular disease*> Neuromuscular disease*    <Suspected additional sleep disorder*> Suspected additional sleep disorder*
<Type II diabetes mellitus> Type II diabetes mellitus    <Neurologic disease*> Neurologic disease*    <Previous failed study*> Previous failed study*    <Nocturia> Nocturia
<Hypothyroidism*> Hypothyroidism* <Hypertension> Hypertension <Respiratory disease*> Respiratory disease*    <Insomnia*> Insomnia*
<Patient prefers lab study*> Patient prefers lab study*    <Body position required*> Body position required*    <Suspected central sleep apnoea*> Suspected central sleep apnoea*
<Suspected narcolepsy*> Suspected narcolepsy*    <Unsuitable for home environment*> 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:	<DrName>	Signature:		Date:	<TodaysDate>	
Provider Number:	<DrProviderNo>	Address:	<DrStreet> <DrCity> <DrPostcode> <DrState>	
cc:	<Copy report to:>