Breathe
  West

NAME: <<Patient Demographics:Full Name>>
ADDRESS: <<Patient Demographics:Address>>

	

PLEASE FAX ALL REFERRALS
FAX: (03) 9011 9671
PH: 8001 7033
ADMIN@BREATHEWEST.COM.AU

	
DOB: <<Patient Demographics:DOB>>   PHONE: <<Patient Demographics:Phone (Home)>>  MEDICARE NO: <<Patient Demographics:Medicare Number>>	
PRIVATE HEALTH:	
YES	
	
NO	

	

		

	REQUEST FOR:
	CLINICAL NOTES: 		

	REFERRING DOCTORS DETAILS: 
<<Doctor:Full Details>>

	COPIES TO:  
 <<Addressee:Full Details>>		

	DOCTORS SIGNATURE: 	                                                                           DATE:<<Miscellaneous:Date (short)>>     		

	SLEEP ASSESSMENT		SLEEP STUDIES		RESPIRATORY ASSESSMENT		LUNG FUNCTION TESTS
(Bulk Bill**)			
	URGENT (appt.within 7Days)		

	Home Based Polysomnography 

	URGENT (appt. within 7 Days)		

	Spirometry & Gas Transfer  		

	Commercial Vehicle Driver or Pilot 		

	In Laboratory Polysomnography 

	Lung Nodule or Lung Mass     		

	Spirometry Without Gas Transfer 		

	Coronary Heart Disease

	Private Hospital	         		

	Severe Respiratory Disease     		

	6 Minute Walk Test			

	Cerebrovascular Accident			

	Public Hospital	          		

	NON URGENT 	                     		

	Bronchoprovocation Test	
(Mannitol Challenge)		

	Hypertension requiring
≥ 3 medications        	

	

NON URGENT	

	

	* 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.

** for Medicare eligible patients and indications.		

	
STOP BANG QUESTIONNAIRE	
Yes	
No	

1: SNORING
 Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?	

 	

	

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?	

	

	

5: BMI
Is your BMI more than 35kg/m2? (If unsure please leave blank)	

	

	

6: AGE
Are you over 50 years old?	

	

	

7: NECK CIRCUMFERENCE
Is your neck circumference greater than 40cm?	

	

	

8: GENDER
Are you male?	

	

	

EPWORTH SLEEPINESS SCALE	

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 	

SITUATION CHANCE OF DOZING
Sitting and reading? 	

Watching TV?	

Sitting, inactive in a public place (eg. a theatre or a meeting)?	

As a passenger in a car for an hour without a break?	

Lying down to rest in the afternoon when circumstances persist?	

Sitting and talking to someone?	

Sitting quietly after a lunch without alcohol?	

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

                                                                    TOTAL SCORE	

		

	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
FAX: (03) 9011 9671
	 ADDRESS: Suite 10, Circle Health, 230 Blackshaws Road Altona North VIC 3025
POSTAL ADDRESS: PO Box 2020, Altona East VIC 3025		

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