Hunter Respiratory and Sleep Centre

25 Molly Morgan Drive, East Maitland

Phone: 02 4018 7506, Fax: 02 4915 5351, Email: reception@hunterrespiratorysleep.com.au

Referral Request

This referral request is to be completed by a Referring Practitioner only. Once the referrer submits the form, a copy of the referral will be sent to our reception and we will contact the patient to make an appointment at the earliest convenience.

Patient Details

Name *

DOB *

Mobile Phone *

Home Phone

Email

Address

Clinical Priority

Urgent (Urgent (e.g. lung tumour, MVA due to sleepiness, etc.) Please call us for an urgent appointment. Semi-urgentRoutine

Respiratory Investigation Only

Pulmonary Function Testing (PFT) (Spirometry and Diffusion Capacity)

Lung Volume

Bronchial Provocation Test for Asthma Need PFT first (Contraindicated if FEV1<70%)

FENO (Assess Steroid Responsiveness)

Skin Allergy Test

MIPS/MEPS (Respiratory Muscle Testing)

Sleep Investigation Only

Diagnostic Sleep Study (Home/In-lab Sleep Study)
Both OSA 50 and ESS questionnaires below must be completed to qualify for a Medicare rebate.

CPAP/BiPAP Titration Study

Diagnostic Study and Day Wakefullness Test (MWT)
Need sleep physician consult to qualify for Medicare rebate

Diagnostic Study and Day Sleep Latency (MSLT)
Need sleep physician consult to qualify for Medicare rebate

Oximetry (non-medicare rebate item)

CPAP/BiPAP/ASV Trial and Technician Review

Physician Consultation

Sleep Consultation

Respiratory Consultation

Brief clinical history

Referring Doctor

Doctor's Name *

Provider Number

Practice Address *

Signature *

Draw signature|Type signatureClear

Date of Referral *

Referring doctor's email *A copy of the referral will be sent to this email

Copy of Referral To (optional):Another copy of the referral will be sent to this email

Medicare Rebate ScreeningQuestionnaire for Sleep Study

It is a Medicare requirement that a patient need to have STOP BANG>3 or OSA 50>5 and ESS>8) to qualify for rebated sleep study without physician consultation. Alternatively, please tick a sleep consultation request and our friendly team will contact the patient to direct an appropriate pathway.

OSA50 Screening Questionnaire

Obesity. Waist circumference Male>102cm or Females>88cm

YesNo

Snoring. Has your snoring ever bothered other people?

YesNo

Apnoea. Has anyone noticed that stop breathing during your sleep?

YesNo

Are you over 50 years old?

YesNo

Total Score

Epworth Sleepiness Scale

How likely are you to doze off (fall asleep) in the following situations?

Use the following scale to choose the most appropriate answer:

0 - No chance

1 - Slight chance

2 - Moderate chance

3 - High chance

Sitting and reading

0123

Watching TV

0123

Sitting, inactive in a public place (e.g. theatre, meeting)

0123

As a passenger in a car for an hour whithout a break

0123

Lying down to rest in the afternoon when circumstances permit

0123

Sitting and talking to someone

0123

Sitting quietly after lunch without alcohol

0123

In a car, while stopped for a few minutes in the traffic

0123

Total Score