FOR ALL APPOINTMENTS PLEASE CALL 1300 391 820	

	

	

NORTH BRISBANE SLEEP AND THORACIC	
Clayfield:  Unit 4/723 Sandgate Road, Clayfield Q 4011
North Lakes:  Suite 207, 53 Endeavour, North Lakes Q 4509	

	

Bulk Billed Sleep Studies and Lung Function Tests*

PATIENT DETAILS
Name	*To qualify for a bulk billed study, all components of the request must be completed and returned by
Medical Objects: North BrisbaneSleep and Thoracic 
or 
FAX: (07) 3036 6094

<<Patient Demographics:Full Name>>		SPECIALISTS	
Address	<<Patient Demographics:Address>>		Dr Andreas Fiene	
	<<Patient Demographics:City>>		Dr Eric Douglas	
DOB	<<Patient Demographics:DOB>>		Dr Gerry Olive	
Telephone	<<Patient Demographics:Phone (Home)>>			
Mobile	<<Patient Demographics:Phone (Mobile)>>			
Medicare	<<Patient Demographics:Medicare Number>>			
Health Fund				
				
CLINICAL QUERY
<<Clinical query?>>

SECTION 1: SERVICE REQUESTED
☐	Diagnostic Sleep Study prior to Sleep Physician Consultation (conditions apply - see section 3, 4 & 5	☐	Sleep Physician Consultation
☐ Pre Sleep Study
☐ Post Sleep Study	
☐	CPAP sleep study. For a bulk billed sleep study, patient must have sleep physician consultation prior	☐	Post Therapeutic Intervention - e.g. upper airway surgery, oral appliance, >10% weight loss, positional therapy, etc. For a bulk billed sleep study, patient must have Sleep Physician consultation prior. 	

SECTION 2: LUNG FUNCTION REQUEST
☐	Comprehensive Lung Function (spirometry, diffusing capacity and absolute lung volumes)	☐	Full Lung Function (spirometry, diffusing capacity)	
☐	Spirometry 	☐	Bronchodilator Response	
☐	Consultation: ☐ Dr Douglas     ☐ Dr Fiene 
☐ Next Available			

SECTION 3: CLINICAL HISTORY 
PAST MEDICAL HISTORY
<<Clinical Details:History List>>

SECTION 4: DIAGNOSTIC SLEEP STUDY REQUEST
Pre- screening for high probability for symptomatic moderate to high OSA. To access a bulk billed sleep study prior to a sleep physician consultation, a patient must have an OSA-50 Score ≥ 5 AND Epworth Sleepiness Scale score ≥ 8.

PLEASE COMPLETE THE FOLLOWING QUESTIONNAIRES: 

OSA-50 Question								                Tick if 'yes'
Is waist circumference > 102cm if male or > 88cm if female 	3	☐	
Has the patient's snoring ever bothered other people? 	3	☐	
Has anyone report apnoeas during the patient's sleep?	2	☐	
Is the patient over 50 years of age?	2	☐	
                                                                         Total for OSA-50			

Epworth Sleepiness Scale score: Rate 0-3 to indicate change of dozing under the circumstances below (0 Unlikely, 1 Slight, 2 Moderate & 3 Highly likely). Score range = 0 to 24. 	           
										Tick one for each question
	0	1	2	3	
Sitting & Reading	☐	☐	☐	☐	
Watching TV	☐	☐	☐	☐	
Passenger in car trip greater than 1 hour	☐	☐	☐	☐	
Sitting and talking to someone	☐	☐	☐	☐	
Sitting inactive in public (meeting or theatre)	☐	☐	☐	☐	
Lying down to rest in the afternoon when circumstances permit	☐	☐	☐	☐	
Sitting after lunch without alcohol	☐	☐	☐	☐	
In a car stopping in traffic for a few minutes 	☐	☐	☐	☐	
                                                                                    Total for ESS					

SECTION 5: SUITABILITY FOR HOME DIAGNOSTIC STUDY
Does the patient have any of the following conditions below? If YES, please tick all that are applicable. if any are present, the patient is not suitable for a home study. 
Other factors may also result in home studies being unsuitable If NONE of the conditions below are present, please tick ☐ 

☐	Unexplained sleepiness (not due to environment/sleep hygiene)	☐	Suspected central sleep apnoea syndrome	
☐	Suspected sleep hypoventilation syndrome 	☐	Significant cardiac arrhythmias / heart failure	
☐	Neurological disease likely (especially neuromuscular disease) 	☐	Acromegaly or hypothyroidism	
☐	Advanced respiratory disease	☐	Possible parasomnia or seizure disorder	
☐	Previous failed or inconclusive 	☐	home study	
☐	Where recording of body position is considered essential 	☐	Unsuitable for home study. State reason:	

❏ OSA-50 score ≥ 5 and ESS ≥ 8 AND None of the criteria in SECTION 5 applicable:
Bulk billed home study without prior sleep consultation
❏ OSA-50 score ≥ 5 and ESS ≥ 8 AND Any one of the criteria in SECTION 5 applicable:
Patient can proceed to a Bulk Billed in lab study
❏  OSA-50 score < 5 or ESS < 8: Patient must proceed to a sleep physician consultation prior to a sleep study OR may access a non- Medicare rebated sleep study

Referring Physician:	<<Doctor:Name>>	Provider No: <<Doctor:Provider Number>>	
Tel: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	Email: <<Doctor:E-mail>>	
Date: <<Miscellaneous:Date (short)>>		Signature:

Patient Instructions		
Spirometry/Lung Function – DO NOT take Ventolin, Bricanyl, Atrovent, Respolin, Asmol (symptom relievers) during the 4 hours before the test.