referral sleep & respiratory phone · referral sleep & respiratory patient name address...
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Referral Sleep & Respiratory
PATIENT NAME
ADDRESS PHONE
DATE OF BIRTH
Phone 9233 5200
Fax9233 5210
Sitting and reading /3
Watching TV /3
Sitting, inactive in a public place (theatre, meeting, etc.) /3
As a passenger in a car for an hour without a break /3
In a car, while stopped for a few minutes in traffic /3
Lying down to rest in the afternoon when circumstances permit /3
Sitting quietly after lunch without alcohol /3
Sitting and talking to someone /3
Total /24
EPWORTH SLEEPINESS SCALE (ESS)
How likely is the patient to doze off or fall asleep in the following situations? Choose the most appropriate number for each situation:
STOP-BANG QUESTIONNAIREAssign 1 point for each ‘Yes’ response
0 = would never fall asleep 1 = slight chance of falling asleep
2 = moderate chance of falling asleep3 = high chance of falling asleep
Does the patient Snore loudly (louder than talking or loud enough to be heard through closed doors)?
Does the patient often feel Tired, fatigued, or sleepy during daytime?
Has anyone Observed the patient stop breathing during their sleep?
Is the patient being treated for high blood Pressure?
Body Mass Index more than 35 kg/m2?
Age: Is the patient over 50 years old?
Is the patients Neck circumference greater than 40 cm?
Gender: Is the patient male?
Total /8Symptomatically sleepy: scoring of 8 or more High risk OSA: answering yes to 4 or more items
COMMERCIAL LICENSE PRIVATE HEALTH INSURANCE CLINICAL HISTORY ATTACHED
OPTION 1 – Physician consultation and sleep study
ATTENDED DIAGNOSTIC UNATTENDED HOME STUDY *Please also complete patient presentation below
NEXT AVAILABLENOMINATED ONLY Refer over page for listing
OPTION 2 – Sleep study (Complete ESS and STOP-BANG)
MEDICARE REQUIREMENTS FOR SLEEP TESTING HAVE CHANGED
As of the 1st November 2018, patients referred directly for a sleep study must report symptomatic sleepiness via an Epworth score ≥8 and have moderate to severe likelihood of Obstructive Sleep Apnoea (OSA) via a STOP-BANG score ≥ 4.
To determine if your patient is eligible for a diagnostic sleep study, please complete the screening tools below. Alternatively, select Option 1 for referral to a Sleep or Respiratory Physician for further investigation into symptoms or for additional testing including CPAP studies.
REFERRAL FOR SLEEP INVESTIGATION
Dr
REFERRING DOCTOR
genesiscare.com
PATIENT PRESENTATION - PLEASE TICK RELEVENT BOXES * indicates an attended (in-lab) sleep study may be required
Cardiac co-morbidities*Neurological disease*Respiratory disease*Hypothyroidism*Neuromuscular disease*
Previous failed study*Suspected central sleep apnoea syndrome*Suspected additional sleep disorders* Unsuitable home environment*Patient preference*
Body position required*Diabetes type 2 NocturiaHypertensionInsomnia*
DyspnoeaWheezeCough
CLINICAL NOTES:
[email protected] | genesiscare.comFormerly: Genesis Sleep & Respiratory Care
Pulmonary Function Testing – Comprehensive With Bronchodilator
Spirometry With Bronchodilator
Six Minute Walk Test Bronchial Provocation Test
RESPIRATORY TESTS REQUIRED
COPY TOSIGNATURE / DATE
083.V
05/
July19
Please print, sign and date
BUNBURY St John of God Bunbury Suite 21, Cnr Robertson Drive & Bussell HighwayT 9720 3403 | F 9720 3410
BUSSELTON 19 Albert StreetT 9720 3403 | F 9720 3410
MANJIMUP Warren District Hospital 1 Hospital AvenueT 9720 3403 | F 9720 3410
MARGARET RIVER Pharmacy 777 Margaret River
1/101 Bussell Highway T 9233 5200 | F 9233 5210
CARNARVON Pharmacy 777 Carnarvon
6 Robinson Street T 9233 5200 | F 9233 5210
PORT HEDLAND Pharmacy 777 Port Hedland
Shop 9, Boulevard Shopping
Centre, Cnr McGregor &
Wilson Street T 9233 5200 | F 9233 5210
KARRATHA Pharmacy 777 Karratha
33 Sharpe AvenueT 9233 5200 | F 9233 5210
JOONDALUP Suite 103, Specialist Medical Centre West Joondalup Health Campus, Shenton AvenueT 9233 5200 | F 9233 5210
Shenton HouseL2 - outpatientsL3 - inpatients sleep lab57 Shenton Avenue,JoondalupT 9233 5200 | F 9233 5210
PERTHMount Medical CentreSuite 3, 140 Mounts Bay RoadT 9233 5200 | F 9233 5210
MURDOCHWexford Medical Centre Suite 68–72, 3 Barry Marshall ParadeT 9233 5200 | F 9233 5210
COCKBURN Cockburn Health & Community Centre Level 1, Suite 11, 11 Wentworth Parade, SuccessT 9233 5200 | F 9233 5210
MANDURAHSouthern Specialists Centre1/5 Murdoch Drive,GreenfieldsT 9233 5200 | F 9233 5210
Dr Hari Adoni
Dr Scott Claxton
Dr Cheng Long Lu
Dr Antonius Steven
Metro Centre Locations
Regional Centre Locations
Sleep & Respiratory Physicians
[email protected] | genesiscare.comFormerly:
APPOINTMENT
Date
Time
Centre Locations
YOKINEDR7 Medical CentreCorner Royal Street and Wanneroo RoadT 9233 5200 | F 9233 5210