Hunter Respiratory and Sleep Centre
Dr Tun Myat, ABN 61 386 775 547	

25 Molly Morgan Drive (Head office)
East Maitland, NSW 2323
4/41 Charles Street (Satellite office)
Warners Bay, NSW 2282	Phone: 02 4018 7506     Fax: 02 4915 5351
Email: reception@hunterrespiratorysleep.com.au
Online referral: www.hunterrespiratorysleep.com.au	

Referral Request	

Patient Details	
Name:	<PtFullName>	DOB:	<PtDoB>	
Contact:	Mobile: <PtPhoneMob>	Home: <PtPhoneH>	Email:	<PtEmail>	
Address:	<PtStreet> <PtCity> <PtPostcode> <PtState>	
Clinical Priority <== CLINICAL PRIORITY ==>	
Urgent (e.g. lung tumour, MVA due to sleepiness etc.) Please call us for an urgent appointment.	<Urgent (e.g. lung tumour, MVA due to sleepiness etc.)>	Semi-urgent	<Semi-urgent>	Routine	<Routine>	
Respiratory Investigation (test only)	Sleep Investigation (test only)	

<== RESPIRATORY INVESTIGATION (TEST ONLY) ==> Pulmonary Function Testing (PFT)
 (Spirometry and Diffusion Capacity)	
<Pulmonary Function Testing (PFT) (Spirometry and Diffusion Capacity)>	

 Lung Volume	
<Lung Volume>	

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

 FENO
 (Assess Steroid Responsiveness)	
<FENO (Assess Steroid Responsiveness)>	

 Skin Allergy Test	
<Skin Allergy Test>	

 MIPS/MEPS
 (Respiratory Muscle Testing)	
<MIPS/MEPS (Respiratory Muscle Testing)>	

<== SLEEP INVESTIGATION (TEST ONLY) ==> Diagnostic Sleep Study
 (Home/In-lab sleep study)
 Both OSA 50 AND ESS questionnaire on the back page
 must be completed to qualify for a Medicare rebate	
<Diagnostic Sleep Study (Home/In-lab sleep study) Both OSA 50 AND ESS questionnaire on the back page must be completed to qualify for a Medicare rebate>	

 PAP/BiPAP Titration Study	
<CPAP/BiPAP Titration Study>	

 Diagnostic Study and Day Sleep Latency (MSLT)
 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.>	

 Diagnostic Study and Day Wakefulness Test (MWT)
 Need sleep physician consult to qualify for Medicare rebate	
<Diagnostic Study and Day Wakefulness Test (MWT). Need sleep physician consult to qualify for Medicare rebate.>	

 Oximetry (non-Medicare rebate item)	
<Oximetry (non-Medicare rebate item)>	

 CPAP/BiPAP/ASV trial and technician review	
<CPAP/BiPAP/ASV trial and technician review>	

	
Respiratory Consultation <==RESPIRATORY CONSULTATION?==>	<Respiratory Consultation>	Sleep Consultation <==SLEEP CONSULTATION?==>	<Sleep Consultation>	
Our team will contact patient for an appointment with our first available physician.	
Brief clinical history:
<Brief clinical history:>
	
Referring Doctor	
Name:	<DrName>	Provider number:	<DrProviderNo>	
Practice address:	<DrStreet> <DrCity> <DrPostcode> <DrState>	
Signature:		Date of Referral:	<TodaysDate>	

Email Report: <Email Report to:>	Copy of Report to: <Copy of Report to:>	
Medicare Rebate Screening Questionnaire for Sleep Study	
Please complete the following screening questionnaires with your patient. 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 (if Yes, please circle score) <==OSA50 SCREENING QUESTIONNAIRE==>	
Obesity	Waist circumference Male>102cm or Females>88cm	<Obesity: Waist circumference Male>102cm or Females>88cm>	
Snoring	Has your snoring ever bothered other people?	<Snoring: Has your snoring ever bothered other people?>	
Apnoea	Has anyone noticed that stop breathing during your sleep?	<Apnoea: Has anyone noticed that stop breathing during your sleep?>	
50	Are you over 50 years old?	<50: Are you over 50 years old?>	
Total Score:	<OSA50 Screening Questionnaire TOTAL:>	
	
Epworth Sleepiness Scale (Please circle your score) <==EPWORTH SLEEPINESS SCALE==>	
How likely are you doze off or fall asleep in the following situations?
This refers to your usual way of life in recent times. 
0 = would never doze off   1 = slight chance  2= moderate chance   3=high chance of dozing <How likely are you doze off or fall asleep in the following situations?>	
Sitting and reading	<Sitting and reading>	
Watching T.V	<Watching T.V>	
Sitting, inactive in a public place (e.g theatre, meeting)	<Sitting, inactive in a public place (e.g theatre, meeting)>	
As a passenger in a car for an hour without a break	<As a passenger in a car for an hour without a break>	
Lying down to rest in the afternoon when circumstances permit	<Lying down to rest in the afternoon when circumstances permit>	
Sitting and talking to someone	<Sitting and talking to someone>	
Sitting quietly after lunch without alcohol	<Sitting quietly after lunch without alcohol>	
In a car, while stopped for a few minutes in the traffic	<In a car, while stopped for a few minutes in the traffic>	
Total score:	<Epworth Sleepiness Scale TOTAL:>	
	
Additional criteria for further assessment for in-lab sleep testing (Please tick if applicable) <==ADDITIONAL CRITERIA FOR FURTHER ASSESSMENT FOR IN-LAB SLEEP TESTING (PLEASE TICK IF APPLICABLE)==>	
Intellectual disability or cognitive impairment	<Intellectual disability or cognitive impairment>	
Physical disability with inadequate care attendance	<Physical disability with inadequate care attendance>	
Neuromuscular disorder	<Neuromuscular disorder>	
Heart failure or suspected central sleep apnoea	<Heart failure or suspected central sleep apnoea>	
Suspected respiratory failure may require TCO2 monitoring	<Suspected respiratory failure may require TCO2 monitoring>	
Suspected parasomnia or sleep movement disorder or seizure disorder	<Suspected parasomnia or sleep movement disorder or seizure disorder>	
Suspected positional sleep apnoea and not recorded as part of unattended study	<Suspected positional sleep apnoea and not recorded as part of unattended study>	
Previously failed or inconclusive unattended study	<Previously failed or inconclusive unattended study>	
Unsuitable home environment including unsafe environments; and	<Unsuitable home environment including unsafe environments; and>	
Consumer preference based on high level anxiety about location of study or where is unreasonable cost or disruption based on distance travel or home circumstances.	<Consumer preference based on high level anxiety about location of study or where is unreasonable cost or disruption based on distance travel or home circumstances.>	

Please stop the following medications before pulmonary function test.	
Short acting bronchodilators (e.g, Ventolin, Asmol, Bricanyl).	Withhold for 6 hours	
Long-acting bronchodilators (e.g, Seretide, Serevent, Flutiform)	Withhold for 12 hours or 48 hours for asthma test	
Ultralong acting bronchodilators (e.g Onbrez, Spioloto, Ultibro, Anoro, Brimica, Breo, Trelegy, Trimbo, Breztri)	Withhold for 24 hours or 72 hours for asthma test	
Oral non-steroid preventers (e.g, Singulair or montelukast)	Withhold for 72 hours for asthma test.	
Oral antihistamines (e.g Telfast, Zyrtec, Loratadine)	Withhold for 5 days for asthma/allergy test