Referral form

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Spirit Sleep & Respiratory: Referral Shop 23 / 6 Belgrave St, Kogarah NSW 2217 · Ph (02) 9564 8626 · Fax [TBC] · clinic@spiritsleeprespiratory.com.au · Secure msg [TBC]

Patient details

Full name Date of birth Phone Medicare no. / ref / expiry Address Height (cm) / Weight (kg) DVA no. (if applicable)

Interpreter required. Language:

Service requested

Diagnostic home sleep study (adult, unattended)

Respiratory function testing: Spirometry (pre/post bronchodilator) Lung volumes [TBC] Gas transfer (DLCO) [TBC]

Asthma education

CPAP initiation / review

Sleep physician review if deemed appropriate

Sleep study eligibility (direct GP referral)

Attach completed questionnaires. Medicare criteria for direct GP referral: ESS ≥ 8 AND at least one of: STOP-Bang ≥ 3; OSA50 ≥ 5; Berlin high risk.

Epworth Sleepiness Scale score: / 24 STOP-Bang score: / 8 OSA50 score: / 10 Berlin: High risk Low risk

OR: I am a qualified sleep medicine practitioner / consultant respiratory physician and have determined this patient requires a sleep study.

Previous sleep study? Date:

Suitability for home study

Tick if present. A sleep physician review or laboratory study may be more appropriate.

Significant cardiorespiratory disease

Neuromuscular disease / suspected hypoventilation

Suspected non-OSA sleep disorder

Cognitive impairment or disability without carer support

Clinical information Symptoms / reason for referral Relevant history and current medications

Referring doctor

Name Provider number Practice address Phone / fax Copy report to Signature Date

Referrals can be addressed to Spirit Sleep & Respiratory. Please send by secure messaging, fax or email, or give to the patient.