Patient Details		
Name: <PtFormalName>
Email: <PtEmail>
Address: <PtStreet>, <PtCity>, <PtPostcode>	DoB: <PtDoB>
Phone: <PtPhoneMob>

<Patients gender>Gender:  <Male> M  <Female> F	
<Patient elgibility>Medicare: <Medicare>   DVA: <DVA>  Defence: <Defence>  WorkCover: <WorkCover>  Private Health Insurance:<Private Health Insurance?> <Yes> Yes <None> None 		

Reason for Referral	  	Clinical Information	
<Tick the reason for the referral><Respiratory Consult> Respiratory Consult
<Occupational Consult> Occupational Consult
<Sleep Consult> Sleep Consult 
<Sleep Consult PLUS Sleep Study> Sleep Consult PLUS Sleep Study 
<Direct to Sleep Study (please refer to MBS criteria below)> Direct to Sleep Study 
 (please refer to MBS criteria below)		<Insert clinical information to support the referral>	
		<Select the doctor for the referral> <Next Available> Next Available   <Preferred doctor> Preferred Doctor: <If preferred doctor is selected, enter the doctors name>	

Lung Function Testing <Select the lung function tests>	
<Comprehensive lung function> Comprehensive lung function (spirometry, diffusing capacity, body plethysmography +/- bronchodilator)	<Spirometry & Diffusing Capacity> Spirometry & Diffusing Capacity	<Spirometry Pre & Post Bronchodilator> Spirometry Pre & Post Bronchodilator	

Important: To qualify for a Medicare subsidised home sleep study, your patient needs to score 3 or more on STOPBANG and 8 or more on ESS. If your patient does not qualify, please refer them for a Sleep Consult PLUS Sleep Study.
Patients must be 18 years or older for this service.	
STOPBANG		EPWORTH SLEEPINESS SCALE (ESS)	
Please tick if applicable. Tick = 1   		How likely the patient to doze off in the following:	
<STOPBANG - Please tick if applicable. Each tick is 1 point><Does the patient snore loudly?> Does the patient snore loudly?
<Does the patient feel tired during the day time?> Does the patient feel tired during the day time? 
<Has anyone observed the patient to have stopped breathing during sleep?> Has anyone observed the patient to have stopped breathing during sleep?
<Is the patient being treated for high blood pressure?> Is the patient being treated for high blood pressure?
<Is the patient’s BMI greater than 35?> Is the patient’s BMI greater than 35?
<Is the patient’s age 50 or older?> Is the patient’s age 50 or older? 
<Is the patient’s neck circumference greater than 40cm?> Is the patient’s neck circumference greater than 40cm?
<Is the patient’s gender male?> Is the patient’s gender male? 

Total:  / 8		Sitting and reading
Watching TV
Sitting, inactive in a public place
Being a passenger in a car for an hour 
without break
Lying down to rest in the afternoon
Sitting and talking to someone 
Sitting quietly after lunch without alcohol 
In a car while stopped for a few 
minutes in traffic 	<EPWORTH SLEEPINESS SCALE (ESS) - How likely the patient to doze off in the following?><Sitting and reading>
<Watching TV>
<Sitting, inactive in a public place>
<Being a passenger in a car for an hour without break>

<Lying down to rest in the afternoon>
<Sitting and talking to someone>
<Sitting quiestly after lunch without alcohol>
<In a car while stopped for a few minutes in traffic> 	
		 	Total:    / 24	
<REMINDER - Manually enter the totals for STOPBANG and EPWORTH SLEEPINESS SCALE (ESS) into the referral after populating all information>
Referrer Details	
Name: <DrName>		Date: <TodaysDate>	
Provider No: <DrProviderNo>	Signature