Phone: (07) 5638 1259
 Fax: (07) 5638 1274 
Email: info@coastalrss.com.au 
Website: www.coastalrespsleep.com.au 
Tugun | Benowa | Southport | Pimpama
	
  RESPIRATORY AND SLEEP REFERRAL 		
Patient Details	
Name:	
<<Patient Demographics:Full Name>>	
DoB:	
<<Patient Demographics:DOB>>	

Email:	
<<Patient Demographics:E-mail>>	
Phone:	
<<Patient Demographics:Phone (Mobile)>>	

Address:	
<<Patient Demographics:Address>>	

Medicare:	

	
DVA:	

	
Work Cover:	

	
Defence	

	
Private Health
Insurance:	

	
Yes	

	
None	
Gender:	

	
M	

	
F	

Reason for Referral	Clinical Information	

	
Respiratory Consult 	

	
Occupational Consult	

	
Sleep Consult	

	
Sleep Consult PLUS Sleep Study 	

	
Direct to Sleep Study
(Please refer to MBS criteria below) 	

	

Next Available	

	
Preferred Doctor:	
___________	

	
Lung Function Testing	

	Comprehensive lung function (spirometry, diffusing 
capacity, body plethysmography +/- bronchodilator) 		

	Spirometry & Diffusing 
Capacity 		

	Spirometry Pre & Post 
Bronchodilator 	
SLEEP STUDY		
Important: To qualify for a direct 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. 
	
STOPBANG
Please tick if applicable: tick = 1 
	EPWORTH SLEEPINESS SCALE (ESS) 	

	
Does the patient snore loudly? 

	

Does the patient feel tired during the day time? 

	

Has anyone observed the patient to have stopped breathing during 
sleep? 	

	
Is the patient being treated for high blood pressure?

	

Is the patient’s BMI greater than 35?

	

Is the patient’s age 50 or older?

	

Is the patient’s neck circumference greater than 40cm? 

	

Is the patient’s gender male?

	

Total: _________ / 8	

	How likely is the patient to doze off in the following scenarios: 	

None
(0)	
Slight
(1)	
Mod
(2)	
High
(3)	

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 

	

	

	

	

Referrer Details	
Name:	<<Doctor:Name>>	Date:	<<Miscellaneous:Date>>	
Provider No:	<<Doctor:Provider Number>>	Signature:		
Send referrals to: Email: info@coastalrss.com.au | Fax: (07) 5638 1274 |
 Medical Objects: Coastal Respiratory and Sleep