Embed Size (px)
Citation preview
Referral Sleep Medicine
Patient name
Address Phone
Date of birth
Option 1 – Physician consultation and sleep study
Freecall 1800 155 225
Fax07 3217 8190
Attended diagnostic Unattended home study*Please also complete patient presentation below
Next available Nominated only Refer over page for listing
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 asleep1 = 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
Cardiac co-morbidities*Neurological disease*Respiratory disease*
Neuromuscular disease*Previous failed study*Suspected central sleep apnoea syndrome*Suspected additional sleep disorders*
Unsuitable home environment*Patient preference*Body position required*
Commercial license Private health insurance Clinical history attached
Clinical notes:
Option 2 – Sleep study (Complete ESS and STOP-BANG)
Medicare requirements for sleep testing have changedReferral for sleep investigation
Dr
Auto pap therapy invitation
Therapy required (clinic locations PTO)
[email protected] | genesiscare.comFormerly: Genesis SleepCare
Referring doctor Copy toSignature/date
Patient presentation - please tick relevant boxes * indicates an attended (in-lab) sleep study may be required
To determine if your patient is eligible for a diagnostic sleep study, please complete the screening tools below. For a Medicare subsidised sleep study, patients referred 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.
Please print, sign and date
BrisbaneRiverCity Private Hospital Level 4, 401 Milton Road, Auchenflower
Sandford Jackson Building Suite 70, Level 3, 40 Chasely StreetAuchenflower
Wesley Medical CentreSuite 46, Level 4, 40 Chasely Street,Auchenflower
BundabergSuite 3, Entrance 1,72 Barolin Street, Bundaberg
Hervey Bay
Suite 4, 156 Urraween Road, Urraween
ToowoombaSt Andrew’s HospitalSuite 22, 280 North Street, Toowoomba
St Vincent’s Private Hospital22-36 Scott Street, Toowoomba
BrisbaneRiverCity Private Hospital Level 4, 401 Milton Road, Auchenflower
The Wesley Hospital Ward 2W, Level 2, Chasely Street, Auchenflower
BundabergSuite 3, Entrance 1,72 Barolin Street, Bundaberg
Mater Misericordiae Hospital313 Bourbong Street, Bundaberg West
GladstoneMater Misericordiae Hospital50 Rossella Street, Gladstone
Gold CoastJohn Flynn Private HospitalLevel 6, 42 Inland Drive, Tugun
Pindara Private HospitalAllchurch Avenue, Benowa
Hervey Bay St Stephen’s Hospital 1 Medical Place, Urraween
MackayMackay Rehabilitation Hospital57 Norris Road, Mount Pleasant
Sunshine CoastBuderim Private Hospital12 Elsa Wilson Drive, Buderim
ToowoombaSt Andrew’s Hospital280 North Street, Toowoomba
Affiliated sleep and respiratory physicians
Prof Roger Allen
Dr Farzad Bashirzadeh
Dr Michael Bint
Dr Ian Brown
Dr Robert Edwards
Dr Shiv Erigadoo
Dr John Feenstra
Dr Geoff Fanning
Dr Leanne Gauld (Paediatrics)
Dr Maurice Heiner
Dr Justin Hundloe
Dr Gonesh Karmakar
Dr Charl Liebenberg
Dr Andrew Pattison
Dr Lee Rafter
Dr Amy Reynolds
Dr Alex Ritchie
Dr Michael Thompson
Dr Sophie Williams
Dr Christopher Zappala
Dr Lauren Galt
Dr Tim Baird
Testing centre locations
CPAP clinics
Formerly: [email protected] | genesiscare.com
Freecall: 1800 155 225Fax: 07 3217 8190Email: [email protected]: Medical Objects SG4066000YF
Centre locations
Urraween Medical Centre
