Website: www.heartscope.com.au
Email: Info@heartscope.com.au
ABN: 29 135 556 204
Ph: 1800 202 111 or 9560 7558
Fax: 1300 793 236 or 8669 4575
REFERRAL FORM	
	
PATIENT DETAILS	
Appointment Date:	Appointment Date	Time:	Miscellaneous.Time	Date of Referral:	Miscellaneous.Date	
Name:	Patient Demographics.Full Name	Date of Birth:Patient Demographics.DOB	
Address:	Patient Demographics.Full Address	
Phone Number:	Patient Demographics.Phone (Home)	Mobile Number:Patient Demographics.Phone (Mobile)	
Medicare Number:	Patient Demographics.Medicare Number	
Clinical Details:	Clinical Details	
Reason for Referral:	Reason for Referral	
Referred By:	Treating Doctor.Name	
Doctor's Address:	Practice.Address	
Doctor's Phone:	Practice.Phone	Provider Number:Treating Doctor.Provider Number	
Doctor's Email:	Treating Doctor.E-mail	Copies To:	
Doctor's Signature:
	
TEST REQUIRED. Note :- To select the boxes, highlight the check box and press X to select the service/s required	
Echocardiogram (TTE)	Cardiologist Consultation	Stress Echocardiogram	
 Initial - Suspected Heart Condition (55126)
For echocardiogram please select indications:
 Symptoms or signs of heart failure
 Ventricular hypertrophy or dysfunction 
 Pulmonary hypertension 
 Valvular disease  Pericardial disease
 Aortic disease     false Congenital heart disease
 Cardiac tumor or thrombus
 Cardiac source of embolus

 Frequent Repeat - Isolated pericardial effusion, pericarditis, commenced medication for non-cardiac purposes that have cardio-toxic side effects (55133)	 General
 Interventional 
false Arrhythmia Clinic (EP)
 CT Coronary Angiogram (CTCA)
    (Specialist referral only)	 Exercise Stress Echo Focused Study (55141)
 Dobutamine Stress Echo (55145) (Privately Billed)
For stress echo please select indications below:
 New typical or atypical angina
 Known coronary disease with symptoms suggestive of ischaemia
 Abnormal resting ECG ? Ischaemia
 Shortness of breath on exertion (SOBOE)? Cause
 Indeterminate lesion on CTCA
 Pre-operative with poor exercise capacity & PHx of IHD, CVA, DM on insulin, or serum Cr >170
 Assessment of valvular disease or ischaemic threshold during exercise prior to intervention
 ? Ischaemia in patient with impaired cognition or expressive language skills	
 ECG Tracing & Formal Report (11704)	 24 Hour BP Monitor (Privately Billed)	 24 Hour ECG Holter Monitor (11716)
can only be claimed once per every 4 weeks	
 Lung Function Test (15 yrs & older) (Combined Spirometry & Gas Transfer Factor)	 Sleep Investigation (18 yrs & older) Home Based Sleep Study (MBBS 12250)    
* Complete questionnaire below	 Sleep & Respiratory Consultation (Bulk Billed)	
GENERAL INFORMATION (Appointments & Enquiries - Ph: 1800 202 111)	
Cardiologists
Dr. Ali Al-Fiadh                   Dr. Dimuth De Silva
Dr. Kon Profitis                   Dr. Ai Vee Ng
Dr. Ravi Iyer                       Dr. Rafi Huq
Dr. Kiran Munnur                Dr. Pavithra Naidu
Dr. Bhupesh Pathik            Dr. John Voukelatos
Dr. Chelliah Gnanaharan   Dr. Sandeep Prabhu
 Dr. Madhu Gopalakrishnan

Cardiothoracic Surgeon
A/Prof Phillip Hayward

Sleep & Respiratory
Dr. Rajiv Sharma      Dr. Hamna Sahi
Dr. Nizam Uddin       Dr. Shahnaz Haque
	Locations
South-East
 Wheelers Hill        Glen Waverley
 Dandenong           Pakenham
East
 Burwood               Mooroolbark
West
 St Albans              Werribee
North
 Thomastown         Bundoora
Inner-City
 Balaclava            Moonee Ponds
Regional Victoria
 Kilmore Hospital

* Please refer to next page for other locations	The Tests - what are they?
Stress Echocardiogram : A test performed to see how your heart muscles work both at rest and under stress. You are required to fast up to 2 hours prior to the test. Check with your doctor whether you should stop taking any medications. 
Echocardiogram : A test that uses sound waves to produce a moving image of the heart. 
Holter Monitor : Electrical activity of the heart is measured over  4 hours using a lightweight monitor attached to a belt.
ECG : A simple test to record the electrical rhythm of the heart.
24 Hour Blood Pressure Monitor (privately billed) : Ambulatory blood pressure monitoring (ABPM) involves measuring you blood pressure for 24 hours as you go about your daily routine and when asleep.
Home Based Sleep Study : The purpose of this test is to identify sleep disorders such as sleep apnoea, in the privacy of your home.
Lung Function Test : To assess airway function & diffusion capacity. 
Consultation: Consultation with the Cardiologist or Other Specialists.
*CT Coronary Angiogram : Specialist Referral required for this procedure.
As per referral - Cardiologist Consultation will be arranged. 

Heartscope Specialist Group
Service from the heart, for the heart.
Clinic +
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Wheelers Hill	Heartscope Wheelers Hill	G1, 202 Jells Rd, Wheelers Hill. 3150	X		X	X	X	X	X	X	X	X	X	X	
Glen Waverley 	Heartscope Glen Waverley 	L1, Suite 11&12, 2 Brandon Park Dr, Glen Waverley. 3150 					X								
Dandenong
	Heartscope Dandenong	40 Stud Rd, Dandenong. 3175	X		X		X	X	X	X		X		X	
Pakenham	Heartscope Pakenham	2 McGregor Rd, Pakenham. 3810	X		X		X	X	X	X	X	X			
Burwood East	Heartscope / Marina Radiology	1 Lakeside Drive, Burwood East. 3151			X		X								
Burwood	Heartscope Burwood	367 Warrigal Road, Burwood. 3125	X		X		X	X	X						
Berwick	Heartscope / Marina Radiology	48 Kangan Drive, Berwick. 3806		X											
Wantirna	Heartscope / Marina Radiology	623 Boronia Rd, Wantirna. 3152					X								
Cranbourne	Heartscope Cranbourne	24 Mundaring Drive, Cranbourne.3977 	X												
Mooroolbark	Heartscope Mooroolbark	1 / 96  Manchester Rd, Mooroolbark. 3138	X		X		X	X	X	X					
St Albans	Heartscope St Albans
	2-4 Collins Street, St Albans. 3021	X		X		X	X	X	X	X	X			
Werribee	Heartscope Werribee	245 Heaths Road, Werribee. 3030	X		X		X	X	X	X	X	X			
Thomastown	Heartscope Thomastown	113 High Street, Thomastown. 3074	X		X	X	X	X	X	X	X	X	X	X	
Caufield South	Heartscope Caufield South	Level 1, 700 Glenhuntly Road, Caufield South. 3162	X												
Balaclava	Heartscope Balaclava	336 Carlisle Street, Balaclava. 3183			X		X	X	X	X					
Bundoora	La Trobe Private Hospital Suites	Cnr Plenty Road & Kingsbury Drive, Bundoora. 3083	X				X								
Moonee Ponds	Moonee Ponds Specialist Centre	827 Mt Alexander Rd, Moonee Ponds. 3039			X		X	X	X	X					
Kilmore	Kilmore Hospital	Rutledge Street, Kilmore. 3764					X								

Note: *For Home Based Sleep Study please complete the Questionnaires below.

The Epworth Sleepiness Scale Test (Medicare Pre-Qualification Test)

SITUATION                                                                                         SCORE

Sitting and reading............................................................................  0  1  2  3
Watching TV.....................................................................................  0  1  2  3
Sitting, inactive in a public place (e.g. theatre or a meeting).............. 0  1  2  3
As a passenger in a car for an hour without break............................  0  1  2  3
Lying down to rest 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
	
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.	

If your patient qualifies on the Epworth Sleepiness Scale Test, please complete the Stop-Bang or OSA 50 Screening Questionnaire below.

Yes    STOP-BANG Sleep Apnea Questionnaire for Patient

‘ 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 of 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 = male? 
                   
Minimum 4 Ticks to Qualify           

OR
	OSA 50 Screening Questionnaire
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 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