Lung and Sleep Victoria/ North West Specialist Centre
For an appointment please complete all details and Fax to 03 93184577. We will contact your patient within 24 hours.
PATIENT DETAILS

<<Patient Demographics:Full Details>>      
Date of Birth:  <<Patient Demographics:DOB>>
Sex : <<Patient Demographics:Gender>>
Medicare number:  <<Patient Demographics:Medicare Number>>  Expiry   <<Patient Demographics:Medicare Expiry Date>>

REFERRING DOCTOR DETAILS
<<Doctor:Full Details>>

DOCTOR SIGNATURE:___________________________________ 	DATE: <<Miscellaneous:Date>>

CLINICAL NOTES: 

ALLERGY
Information needed:
Are RAST or other relevant test results available? 
Note: For patch testing assessment of contact hypersensitivity by nickel allergy, please refer the patient to a dermatologist

MAJOR PROBLEMS

SLEEP STUDY
SERVICES REQUIRED: 

CLINICAL DETAILS

Note: This request includes referral to a qualified sleep physician who will confirm the necessity for a sleep study, where requested, as per Medicare requirements.

SLEEP MEDICINE
Diagnostic sleep study (see Note) Sleep physician consultation:
•	 Pre-study
•	Post-study
Clinical Details

•	ESS score of 8 or more
•	STOP-BANG Score of 3 or more
•	OSA-50 of 4 or more
•	Snoring
•	Daytime tiredness
•	Witnessed apnoeas
•	Hypertension
•	Atrial fibrillation

STOP-BANG SLEEP QUESTIONNAIRE 
(to be completed with patient)
Please answer all the questions     Yes	No
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?     Y/N	
Do you often feel TIRED, fatigued, or sleepy during daytime?	                                              Y/N	
Has anyone OBSERVED you stop breathing or choking during your sleep?                              Y/N      
 Do you have or are you being treated for high blood PRESSURE?                                                   Y/N	
BMI more than 35kg/m2?                                 Y/N	
AGE over 50 years old?	                               Y/N
      NECK size large? ** (Males:43cm+ & Females:41cm+)                                              Y/N	
      GENDER: Male?       Y/N		   

      Total Score =>
      A STOP-BANG Score of 3-8 identifies petients with a high probability of moderate/severe OSA and is required for MBS funding

EPWORTH SLEEPINESS SCALE QUESTIONNAIRE 
(to be completed with patient)
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    3 = high chance of dozing
     dozing

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? 
This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently try to work out how they would have affected you.
Situation (It is important that you answer each question as best you can)	
•Chance of Dozing (0-3)	
•Sitting and reading	 
•Watching TV		
•Sitting, inactive in a public place (e.g. 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 permit	
•Sitting and talking to someone		
•Sitting quietly after a lunch without alcohol	
•In a car, while stopped for a few minutes in the traffic	
	
Total Score:	
Score Result:
0 – 7 = Normal
      8 – 24 = Abnormal (qualifies for Medicare Bulk-billing rebate

     LUNG FUNCTION
     RESPIRATORY TESTS REQUIRED:

IMPORTANT PRIOR TO RESPIRATORY TESTS:
No short term bronchodilators to be used for 4 hours, unless required (eg Ventolin, Atrovent, Asmol etc)
No long term bronchodilators to be used for 12 hours, unless required (eg Serevent, Oxis, Seretide, Symbicort etc)

LOCATIONS	
FOR ALL APPOINTMENTS PHONE 1300 292 022	PHYSICIAN CONSULT	SLEEP STUDY	LUNG FUNCTION	ALLERGY CONSULT	
Western	
FOOTSCRAY	Footscray Consulting Rooms, 35 Summerhill Road, 3011	•	•	•	•	
SUNBURY	Sunbury Suites, 17–19 Horne Street, 3429	•				
SYDENHAM	Sydenham Specialist Suites, 574 Melton Highway, 3037	•	•	•		
WERRIBEE	Wyndham Private Consulting Rooms, Level 1, 242 Hoppers Lane, 3030	•	•	•		
WILLIAMSTOWN	Williamstown Consulting Rooms, 110 Douglas Parade, 3016	•				
Northern	
BRUNSWICK	80 Moreland Road, Brunswick, 3056	•	•			
BUNDOORA	Northside Specialist Clinic, 209/12 Ormond Blvd, Bundoora, 3083	•	•			
NIDDRIE	Northwest Specialist Centre, Level 1/326 Keilor Road, Niddrie, 3042	•	•	•	•	
Eastern / South Eastern	
BOX HILL	Box Hill Consulting Rooms, Suite 4, 28–32 Arnold Street, 3128	•	•	•		
EAST MALVERN	Central Park Specialist Centre, 389 Wattletree Road, 3145	•	•	•		
HAWTHORN EAST	Cabrini Specialist Centre, Level 2, 141 Camberwell Road, 3123	•	•	•	•	
MALVERN	Cabrini Medical Centre, Suite 32, 183 Wattletree Road, 3144	•	•	•	•	
Bayside / Peninsula	
FRANKSTON	Peninsula Private Hospital, Suite 7, 525 McClelland Drive, 3199		•	•		
PATTERSON LAKES	Bayside Specialist Centre, Suite 29, Level 1, 21 Thompson Road, 3197	•	•	•		
Regional	
BALLARAT	Ballarat Group Practice (Telehealth), 1730A Sturt Street, Alfredton, 3350	•	•			
BACCHUS MARSH	Bacchus Marsh Specialist Centre, 32 Gisborne Road, 3340	•	•	•	•	
FOSTER	Foster Medical Centre (Telehealth), 97 Station Road, 3960	•	•	•	•	
GISBORNE	Gisborne Medical Centre (Telehealth), 16 Brantome Street, 3437	•	•			
LEONGATHA	Leongatha Hospital (Telehealth), 64 Koonwarra Road, 3953	•	•	•	•	
SEBASTOPOL	Sebastopol Consulting Rooms (Telehealth), 49–51 Albert Street, 3356	•	•			
SEYMOUR	Seymour Medical Clinic (Telehealth), 30–32 Anzac Avenue, 3660	•	•