Online Referral Form Date of Referral(Required) DD slash MM slash YYYY Patient DetailsName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Date of Birthday(Required) Day Month Year Phone(Required)Medicare Number(Required)Clinical Indications for Test / Relevant Medical HistoryCurrent Medication/sReferring Doctor DetailsName(Required) DrDr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last PhoneClinic NameDoctor Provider NumberSignature(Required)Consultations Peri-operative Consultation - assessment of patient prior to surgery Cardiac Investigations Echocardiogram Stress Echo - Comprehensive (includes stress and rest echo) Stress Echo - Focused Study (LV function assessment only) ECG Tracing & Report 24 Hour Holter Monitor 24 Hour BP Monitor Event monitor (specify days below) Ankle Brachial Index Respiratory Investigation Lung Function Test (15 years & older) (Combined Spirometry & Gas Transfer Factor) Type II Home Sleep Investigation (18 years & older) 2. The Epworth Sleepiness Scale TestHow likely are you to doze off or fall asleep in the situations described, 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 have affected you. Use the scale test on the left to choose the most appropriate number for each situation.Sitting and reading(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Watching television(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting inactive in a public place (eg. theatre or meeting)(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing As a passenger in a car for an hour without a break(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Lying down in the afternoon when circumstances permit(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and talking to someone(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting quietly after lunch without alcohol(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing In a car, while stopped for a few minutes in traffic(Required) Would never doze Slight chance of dozing Moderate chance of dozing High chance of dozing Epworth Sleepiness Scale Test score0- 7=Normal (Bulk Billing not applicable) 8 - 24 = Abnormal3. STOP - BANG Questionaire Tick if relevant(Required) Do you SNORE loudly (loud enough to be heard through closed doors)? Do you often feel TIRED, fatigued or sleepy during daytime? Has anyone OBSERVED you stop breathing or choking during your sleep? Do you have or are you being treated for high blood PRESSURE? BMI more than 35 kg / m2? AGE older than 50 years? NECK size large (Males: 43cm+ & Females: 41cm+) GENDER = Are you male? Minimum 4 ticks to qualify for Bulk-BillingSTOP BANG score Why wait or pay too much for diagnostic tests?Bulk billed appointments available within 1 week For all your heart, lung, and sleep tests Book Now Referral Form Contact Us
