Suite 1.16A Level 1 Orion Shopping Centre
1 Main Street
Springfield Central QLD 4300
P: 07 3444 4415
F: 07 3470 5852
E: admin@smartcarediagnostics.com.au
REFERRAL FORM	
Please scan to request an appointment	
PATIENT DETAILS	
Date of Referral:	<TodaysDate>	Time:	<CurrentTime>	
Name:	<PtFullName>	Date of Birth:	<PtDoB>	
Address:	<PtAddress>	
Phone Number:	<PtPhoneH>	Mobile Number:	<PtPhoneMob>	
Medicare Number:	<PtMCNo>	
REFERRAL PATHWAY (to ensure medicare bulk billed investigations for your patient)	

c  Specialist Consultation - (assessment of patient for further investigations)
c  Perioperative Consultation - (assessment of patient prior to surgery)
c  Alternatively - select from below investigations required – (ensure Medicare clinical indicators are met)	
CARDIAC INVESTIGATIONS (All tests Bulk Billed except 24hr Blood Pressure Monitoring)
Note :- To select the boxes, highlight the check box and press X to select the service/s required	
Echocardiogram	Stress Echocardiogram	Exercise Stress Test	
c Initial - Suspected Heart Condition
Please select indications below:
c Symptoms or signs of heart failure
c Dyspnoea                           c Murmur
c Palpitations                        c Aortic disease
c Pre-syncope/Syncope        c Valvular disease
c Chest Pain/Discomfort       c Hypertension
c Odema/Peripheral Odema
c Ventricular hypertrophy or dysfunction
c Pulmonary hypertension     
c Pericardial disease              
c Congenital heart disease    
c Cardiac tumour or thrombus
c Cardiac source of embolus

c Agitated Saline Bubble Study
c Frequent Repeat - Isolated pericardial effusion, pericarditis, commenced medication for non-cardiac purposes that have cardio toxic side effects	c Stress Echo - Comprehensive 
(Includes stress echo & resting echo)
c Stress Echo - Focused Study 
(LV function assessment only)
Please select indications below:
c Chest Pain/Discomfort
c Symptoms of typical or atypical angina
c Exertional Symptoms
c Symptoms relieved with GTN or rest
c Unexplained breathlessness
c Shortness of breath on exertion (SOBOE)
c ECG changes suggestive of ischaemia
c Known CAD with worsening symptoms
c Previous cardiac event STENT/MI and worsening symptoms
c Functional assessment of CAD detected on Angio/CT
c Perioperative assessment prior to surgery (poor exercise  capacity & PHx of CAD, DM on insulin, or renal dysfunction)
c Assessment of valvular disease prior to intervention
c Suspected silent myocardial Ischaemia 	c  Exercise Stress Test

Please select indications below:
c Symptoms consistent with cardiac ischaemia
c Exertional Symptoms
c First degree relative with suspected heritable arrhythmia
c Work related screening (Not covered by Medicare)
	
c ECG Tracing & Report 	c 24 Hour BP Monitor (out of pocket cost)	c Ankle Brachial Index	
c 24 Hour Holter Monitor 	c   Multi-Day Holter Monitor 
(please specify number of days _______ 3 -5 days)		
RESPIRATORY & SLEEP INVESTIGATIONS (All tests Bulk Billed )	
c Lung Function Test (15 yrs & older)
(Combined Spirometry & Gas Transfer Factor)	c Type II Home Sleep Investigation (18 yrs & older)
* Complete questionnaire below	
		
Clinical Details:	<Clinical Details>	
Reason for Referral:	<Reason for Referral>	
		
Referred By:	<DrName>	
Doctor's Address:	<DrAddress>	
Doctor's Phone:	<DrPhone>	Provider Number:	<DrProviderNo>	
Doctor's Email:	<DrEmail>	Copies To:	<Copies To>	
Doctor's Signature:
	
Please send referral via Fax 07 3470 5852 or Email to admin@smartcarediagnostics.com.au  or MedicalObjects	

SLEEP STUDIES QUESTIONARIE
Note: *For Home Based Sleep Study please complete the Questionnaires below.
1. Medical Co-Morbidities (Please complete as appropriate)	
Height (cm) =	

Weight (kg) =	

BMI (kq/m2) =	

	
	
Type 2 diabetes	
	
AF	
	
Cardiac failure	
	
Stroke/TIA	
	
COPD	

	

	

	

	
Other Co-Morbidities:	

	

	

	
Previous Sleep Study	
	
YES	
	
NO	
	
Date: 	

	

	

2. The Epworth Sleepiness Scale Test (Medicare Pre-Qualification Test)	
PLEASE CIRCLE
Scenario	

	

Sitting and reading 	
0	
1	
2	
3	

Watching television 	
0	
1	
2	
3	

Sitting inactive in a public place (eg. theatre or meeting) 	
0	
1	
2	
3	

As a passenger in a car for an hour without a break	
0	
1	
2	
3	

Lying down in the afternoon when circumstances permit 	
0	
1	
2	
3	

Sitting and talking to someone	
0	
1	
2	
3	

Sitting quietly after lunch without alcohol	
0	
1	
2	
3	

In a car, while stopped for a few minutes in traffic 	
0	
1	
2	
3	

TOTAL SCORE (add up total responses)	

	

	
0 - Would never doze
1 - Slight chance of dozing
2 - Moderate chance of dozing
3 - High chance of dozing

Score Result:
0 -  7 = Normal
(Bulk Billing not applicable)

8 - 24 = Abnormal
(Complete Questionnaire)

Total = ......................	
How 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. 	
3. STOP-   BANG Questionaire                                OR    OSA 50 Screening Questionaire	

c  Do you SNORE loudly (loud enough to be heard through closed doors)?
c  Do you often feel TIRED, fatigued or sleepy during daytime?
c Has anyone OBSERVED you stop breathing of choking during your sleep?
cDo you have or are you being treated for high blood PRESSURE?
c BMI more than 35 kg / m2?
c AGE older than 50 years?
c NECK size large (Males: 43cm+ & Females: 41cm+)
c GENDER = Are you male?

Minimum 4 ticks to Qualify	

OR	
To qualify for Bulk-Billing a patient must score 5 or more.

Obesity
Waist Circumference: ................... cm ------------------------ = 3
(Male > 102cm & Female > 88cm *Waist measurement at the umbilicus level)
Snoring
Has your snoring ever bothered other people --------------- = 3
Apneas
Has anyone noticed that you stop breathing during sleep = 2
Age 50+
Are you aged over 50 years or over? -------------------------- = 2
Total Score: ................ / 10	
====
TEST INFORMATION	
1.  Echo	(Transthoracic) ultrasound examination of the heart.	
Duration:	40 minutes	
Preparation:	No preparation is necessary.   	
2. Stress Echo	Echo before and after treadmill exercise.	
Duration:	1 – 1.5 hours including recovery time.	
Preparation:	Do not drink beverages containing caffeine (inc Tea/ Coffee/Cola/Energy Drinks) the day of your test. Do not smoke 3 hours prior to your test. Wear clothing and footwear suitable for exercise (suggest shorts/tights for ladies). A gown will be provided. Bring a list of any medications that you are on.	
3. ECG	Standard 12 lead electrocardiograph.	
Duration:	5 - 10 minutes.	
     Preparation:	No preparation is necessary.   	
4. Stress Test	ECG with treadmill exercise.	
Duration:	40 minutes.	
Preparation:	Do not drink beverages containing caffeine (inc Tea/ Coffee/Cola/Energy Drinks) the day of your test. Do not smoke 3 hours prior to your test. Wear clothing and footwear suitable for exercise (suggest shorts/tights for ladies). A gown will be provided. Bring a list of any medications that you are on.	
5. Holter	24 hour ambulatory ECG monitoring.	
Duration:	20 minutes to attach 	
Preparation:	Clean, dry skin is required. You cannot shower whilst you are wearing the monitor for 24 hours, so it is suggested you shower prior to the fitting.  You will be asked to return the monitor in 24 hours.	
6. Ambulatory BP	Blood Pressure Monitor. 24 hour recording worn on the arm.	
Duration:	20 minutes to attach 	
Preparation:	Shower before the test (as you will not be able to shower for 24 hours). You will be asked to return the monitor in 24 hours.	
6. Home Sleep Study		
Duration:	20 minutes to attach – 5 minutes to detach.	
Preparation:	Please shower before your sleep study as once the electrodes and wires are applied you will not be able to shower until the next morning.  If you are normally clean-shaven, please shave before your sleep study.  Please try to avoid nail polish as you will be wearing a finger oximeter.