Online Referral for GP

Patient Details

(Please Tick Appropriate Boxes Below)

Appointment Details

General Physician

Cardiac Services
Initial Assessment Pharmacological Stress Echo (55145) (Subject to a 2 year referral restriction, cannot be claimed if stress echo was claimed within 24 months)
For echocardiogram please select indications below:
*
For stress echo please select indications below:
Initial Assessment Pharmacological Stress Echo (55145) (Subject to a 2 year referral restriction, cannot be claimed if stress echo was claimed within 24 months)
Sleep & Respiratory Services
(Combined Spirometry & Gas Transfer Factor)
Home based Sleep study (MBS 12250) For suspected sleep apnea. If deemed necessary, a Sleep Physician appointment may be arranged, who will arrange appropriate treatment if required.
Preferred Location/s *
Disclaimer : Not all procedures may be available at the selected location(s).

For Sleep Studies please complete questionnaire below :

The Epworth Sleepiness Scale Test
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.

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

0
0
0
0
0
0
0
0

Score Result:
0 - 7 = Normal
(Bulk billing not applicable)
8 - 24 = Abnormal (Complete questionnaire below)

Fill in either one of the following:

Stop - Bang Sleep Apnea Questionnaire for Patient :
Minimum 4 Ticks to Qualify *
Do you SNORE loudly (loud enough to be heard through closed doors?)
Do you often feel TIRED, fatigued or sleepy during anytime?
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 35kg/m2?
AGE older than 50 years?
NECK size large (Males: 43cm+ & Females: 41cm+)?
GENDER = male?

OSA 50 Screening Questionnaire
To Qualify for Bulk-Billing a patient must score 5 or more
(Male > 102cm & Female > 88cm *Waist measurement at the umbilicus level) = 3
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
.........../10

Referring Doctor Details

Acknowledgement

By pressing the Submit button, you acknowledge that you are a medical practitioner wishing to make a referral and you have checked to ensure all the correct information has been entered. If you are NOT a medical practitioner, please note that the named patient will not be able to claim Medicare benefits without a valid referral.