Western
Sleep & Breathing
Clinic
Phone: 8001 7033
PLEASE EMAIL REFERRALS TO: admin@breathwest.com.au
OR FAX ALL REFERRALS TO: 9011 9671
ADDRESS: Suite 10, Circle Health, 230 Blackshaws Road Altona North VIC 3025
POSTAL ADDRESS: PO Box 2020, Altona East VIC 3025	
NAME:  Patient Demographics.Full Name
ADDRESS:  Patient Demographics.Full Address
DOB:  Patient Demographics.DOB   PHONE: home: Patient Demographics.Phone (Home);  mobile: Patient Demographics.Phone (Mobile)     MEDICARE NO: Patient Demographics.Medicare Number 
PRIVATE HEALTH: YES  NO                                                                            Copies To: 
Referring doctor details:  Treating Doctor.Full Details		
DOCTORS SIGNATURE:                                                        digitally signed                                                        DATE:  Miscellaneous.Date	
SLEEP ASSESSMENT	SLEEP STUDIES	RESPIRATORY ASSESSMENT	LUNG FUNCTION TESTS   [bulk billed for medicare eligible indications]            	
 URGENT (appt. within 7 days)                                 	 Home Based Sleep Study [polysomnography]                   	  URGENT (appt. within 7 Days)                	 Spirometry & Gas Transfer                            	
 NON URGENT                      	  In Laboratory Sleep Study                  [polysomnography]              	 NON URGENT                                 	 Spirometry Without Gas Transfer               	
 Commercial Vehicle Driver or          Pilot 	 Private Hospital                                                	false  Lung Nodule or Lung Mass                                  	 6 Minute Walk Test                                  	
false Coronary Heart Disease    	 Public Hospital                                      	  Severe Respiratory Disease                                        	 Bronchoprovocation Test
(Mannitol Challenge)                                 	
 Cerebrovascular Accident 				
 Hypertension requiring
≥ 3 medications    	

 * 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.                          
Stop Bang Questionnaire                                         Yes      No	  Epworth Sleepiness Scale	
1. SNORING                                                                        
Do you snore loudly (louder than talking or loud 
enough to be  heard through close doors?                     false       	How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling tired? This refers to your usual way of life in recent times.

USE THE FOLLOWING SCALE TO CHOOSE THE MOST APPROPRIATE NUMBER FOR EACH SITUATION:

0 -Would never Doze                         1 - Slight chance of dozing

2- Moderate chance of dozing             3- High chance of dozing	
2. TIRED                                                                     
Do you often feel tired,fatigued or sleepy 
during daytime?                                                               
3, OBSERVED
Has anyone observed you stop breathing 
 during your sleep?                                                           		
 4. BLOOD PRESSURE
Do you have or are you being treated for high blood               
pressure?	
SITUATION CHANCE OF DOZING:
	
5.BMI
Is your BMI more than 35kg/m2? 
(If  unsure please leave blank)                                             	Sitting and reading?		
	Watching TV?		
	Sitting, inactive in a public place (eg. a theatre or a meeting)?		
6.AGE
Are you 50 years old?                                                       	As a passenger in a car for an hour without a break?		
	
Lying down to rest in the afternoon when circumstances persist?		
7. NECK CIRCUMFERENCE
Is your neck circumference greater than 40cm?                    false    	
Sitting and talking to someone?		
	
Sitting quietly after a lunch without alcohol?		
8.GENDER
Are you male?                                                                 	
In a car, as the driver, while stopped fora few minutes in traffic?		
*** We also consult from Hoppers Crossing, North Melbourne, St Albans & Gisborne.***                                   TOTAL SCORE                                                                                          		

Clinical Notes:   
Past Medical History:   
Current ProblemsClinical Details.Problem List (Current) With Comments
Resolved ProblemsClinical Details.Problem List (Resolved) With Comments
Allergies:  Clinical Details.Allergies With Comments
Note:  Clinical Details.Warnings
Current Medications:Clinical Details.Medication List

We also consult from Hoppers Crossing, North Melbourne, St Albans & Gisborne.