Breathe
West	Western
Sleep & Breathing
Clinic	
NAME: <PtFullName>	PLEASE FAX ALL REFERRALS
ADDRESS: <PtStreet> <PtCity> <PtState> <PtPostcode>	FAX: (03) 9011 9671
DOB: <PtDoB> PHONE: <PtPhoneMob>	EMAIL: admin@breathewest.com.au
PRIVATE HEALTH: <PRIVATE HEALTH>	PH: 1300 487 588
MEDICARE: <PtMCNo> <PtMCLine> <PtMCExpiry>	
REQUEST FOR: <REQUEST FOR:>
CLINICAL NOTES: <CLINICAL NOTES:>
REFERRING DOCTORS DETAILS:	 <DrName>
Provider No. <DrProviderNo>	<Practice>
Phone No. <DrPhone>	<DrStreet> <DrCity> <DrState> <DrPostcode>
COPIES TO: <COPIES TO:>

DOCTOR SIGNATURE: ___________________________________	DATE: <TodaysDate>
SLEEP ASSESSMENT<SLEEP ASSESSMENT>
URGENT (appt. within 7 Days)	<URGENT (appt. within 7 Days)>
Commercial Vehicle Driver or Pilot	<Commercial Vehicle Driver or Pilot>
Coronary Heart Disease	<Coronary Heart Disease>
Cerebrovascular Accident	<Cerebrovascular Accident>
Hypertension requiring ³ 3 medications	<Hypertension requiring 3 or more medications>
NON URGENT	<NON URGENT>	SLEEP STUDIES*<SLEEP STUDIES>
Home Based Polysomnography	<Home Based Polysomnography>
In Laboratory Polysomnography	<In Laboratory Polysomnography>
Private Hospital	<Private Hospital>
Public Hospital	<Public Hospital>
* To be considered for direct referral for a sleep study please complete the Epworth Sleepiness Scale and STOP BANG Form. MBS criteria requires ESS ≥ 8 and STOP BANG ≥ 4 to be eligible for direct referral for a sleep study.	

RESPIRATORY ASSESSMENT<RESPIRATORY ASSESSMENT>
URGENT (appt. within 7 Days)	<URGENT (appt within 7 Days)>
Lung Nodule or Lung Mass	<Lung Nodule or Lung Mass>
Severe Respiratory Disease	<Severe Respiratory Disease>
NON URGENT	<NON URGENT.>	
LUNG FUNCTION TESTS*
<LUNG FUNCTION TESTS>
Spirometry & Gas Transfer	<Spirometry & Gas Transfer>
Spirometry Without Gas Transfer	<Spirometry Without Gas Transfer>
6 Minute Walk Test	<6 Minute Walk Test>
Bronchoprovocation Test (Mannitol Challenge)	<Bronchoprovocation Test (Mannitol Challenge)>	
STOP BANG <STOP BANG>
1. SNORING	<SNORING Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?>
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
2. TIRED	<TIRED Do you often feel tired, fatigued, or sleepy during daytime?>
Do you often feel tired, fatigued, or sleepy during daytime?
3. OBSERVED	<OBSERVED Has anyone observed you stop breathing during your sleep?>
Has anyone observed you stop breathing during your sleep?
4. BLOOD PRESSURE	<BLOOD PRESSURE Do you have or are you being treated for high blood pressure?>
Do you have or are you being treated for high blood pressure?
5. BMI	<BMI Is your BMI more than 35kg/m2? (If unsure please leave blank)>
Is your BMI more than 35kg/m2? (If unsure please leave blank)
6. AGE	<AGE Are you over 50 years old?>
Are you over 50 years old?
7. NECK CIRCUMFERENCE	<NECK CIRCUMFERENCE Is your neck circumference greater than 40cm?>
Is your neck circumference greater than 40cm?
8. GENDER	<GENDER Are you male?>
Are you male?	EPWORTH SLEEPINESS SCALE
<EPWORTH SLEEPINESS SCALE>
Sitting and reading	<Sitting and reading?>
Watching TV	<Watching TV?>
Sitting, inactive in a public place?	<Sitting, inactive in a public place (eg. a theatre or a meeting)?>
(eg. a theatre or a meeting)
As a passenger in a car for an hour?	<As a passenger in a car for an hour without a break?>
(without a break)
Lying down to rest in the afternoon?	<Lying down to rest in the afternoon when circumstances permit?>
(when circumstances permit)
Sitting and talking to someone?	<Sitting and talking to someone?>
Sitting quietly after a lunch?	<Sitting quietly after a lunch without alcohol?>
(without alcohol)
In a car, as the driver, while stopped 
for a few minutes in traffic?	<In a car, as the driver, while stopped for a few minutes in traffic?>	
_____________________________________________________________________________________________________________________________________________________________
Frances Chung, F.R.C.P.C.,
Anesthesiology 2008; 108:812–21 Copyright © 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
_____________________________________________________________________________________________________________________________________________________________
WEB: www.breathewest.com.au	ADDRESS: Suite 10, Circle Health, 230 Blackshaws Road Altona North VIC 3025
FAX: (03) 9011 9671	POSTAL ADDRESS: PO Box 2020, Altona East VIC 3025
We also consult from Hoppers Crossing, North Melbourne, St Albans & Gisborne.