REFERRAL FORM	

Please scan to request an appointment	

	All BOOKINGS
PH: 1 300 358 706
Springfield Central
Fax: 07 3470 5852
Email: bookings@smartcd.com.au	
North Lakes
Email: bookings@smartcd.com.au	

Upper Mt Gravatt
Fax: 07 2800 8797
Email: bookings@smartcd.com.au
Capalaba
Fax: 07 2800 8797
Email: bookings@smartcd.com.au	
Taringa
Email: bookings@smartcd.com.au	

                                                    
 Patient Details	
 Surname
 <<Patient Demographics:Surname>>	
	
 Phone Number
 <<Patient Demographics:Phone (Mobile)>>	

	

 Given Names
 <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
	
 Medicare No
 <<Patient Demographics:Medicare Number>>	

	

 DOB
 <<Patient Demographics:DOB>>	
	
 Email
 <<Patient Demographics:E-mail>>	

Consultations	
c  Perioperative Consultation - (assessment of patient prior to intermediate-high risk surgery)	
Cardiac Investigations (All Tests Bulk Billed)	
c Echocardiogram
      Please select indications below:

c Symptoms or signs of            heart failure	
c Murmur	

c Dyspnoea 	
c Aortic disease	

c Palpitations 	
c Valvular disease	

c Pre-syncope/Syncope	
c Hypertension	

c Chest Pain/Discomfort	

c Odema/Peripheral Odema	

c Ventricular hypertrophy or dysfunction	

c Pulmonary hypertension	

c Pericardial disease	

c Congenital heart disease	

c Cardiac tumor or thrombus	

c Cardiac source of embolus	

c  Frequent Repeat - Isolated pericardial effusion, 
         pericarditis, commenced medication for non-cardiac 
         purposes that have cardio toxic side effects

c Agitated Saline Echo (for PFO)
	c Stress Echo - Comprehensive 
        (Includes stress echo & resting echo)
   Please select indications below:
c Chest Pain/Discomfort
c Stress 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 of PHx or CAD, DM on Insulin
     or renal dysfunction)
c Assessment of valvular disease prior to intervention
c Suspected silent myocardial Ischaemia 	
c ECG Tracing & Report 	
c 24 Hour BP Monitor	
c Ankle Brachial Index	

c 24 Hour Holter Monitor 	
c Event Monitor 
        (Please specify number of days ______ 7-30 days)	

	
Respiratory & Sleep Investigations (all test 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:	

	
Current medications 		Patient history
		Referring Doctor Details	

c Betablocker

c ACE Inhibitor / CCB

c Statin

c Antiplatlet Therapy	

		c Hypertension

c Dyslipidaemia

c Family history

c Diabetes

c Smoker	

		Name          : <<Doctor:Name>>	

Provider No : <<Doctor:Provider Number>>	

Address       : <<Doctor:Full Address>>

Signature:

Date: <<Miscellaneous:Date>>	

=

Fax/Email referral to preferred location	Please refer to back page for full clinic location information	

  
 Home Sleep Studies Questionnaire 
1. Medical Co-Morbidities (Please complete as appropriate)	
  Height (cm) =	

Weight (kg) =	

BMI (kg/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 have not 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 Questionnaire                                 OR    OSA 50 Screening Questionnaire	

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 or choking during your sleep?
c Do 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 for Bulk-Billing 	

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 50 years or over? -------------------------- = 2
Total Score: ................ / 10	

CLINIC LOCATIONS	
Springfield Central                                                                         North Lakes	
Suite 1.16A Level 1, Orion Springfield Central
1 Main Street, Springfield Central, QLD 4300
Opening Hours : Monday to Friday 8am to 5pm
Fax : 07 3470 5852
Email :   bookings@smartcd.com.au	
3/9 Gregor Street West
North Lakes 4509
Email:   bookings@smartcd.com.au	

Upper Mt Gravatt                                                                            Taringa	
2166 Logan Road, Upper Mt Gravatt, QLD 4122
Opening Hours : Monday to Friday 8am to 5pm
Fax : 07 2800 8797
Email :  bookings@smartcd.com.au	
Suite 2, 165 Moggill Road
Taringa Q 4068
(Located inside Integrated Gut Health)
Email:  bookings@smartcd.com.au	

Capalaba	
Shop 27, 200 Old Cleveland Road, Capalaba, QLD 4157
Fax: 07 2800 8797
Email :  bookings@smartcd.com.au	
Please refer to our website for the testing information                             www.smartcd.com.au