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NBST Lung & Sleep Referral Form

Patient details

Date of referral: *This question is required. This question requires a valid date format of DD/MM/YYYY.

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Patients first name *This question is required.

last name *This question is required.

Date of birth: *This question is required. This question requires a valid date format of DD/MM/YYYY.

calendar

Medicare number: *This question is required.

Phone number: *This question is required.

Patient Email: This question requires a valid email address.

Send a copy of the referral to the patient's email address:

Patient Address

Clinical History *This question is required.

Referring Doctor: *This question is required.

Is the referring Doctor a qualified adult sleep medicine practitioner or consultant respiratory physician?

Provider number: *This question is required.

Referring phone number:

Please send additional copy of results to: *This question is required.

1. Doctor's signature *This question is required.

Clear

Signature of

Type of referral: *This question is required.

Lung Function Referral

Please note that lung function testing and consultations incur an out of pocket fee (not bulk billed).

Step 1. Lung Clinical History

Smoking status *This question is required.

Smoking packs years: (20 cigarettes/day on average = 1 pack year)

Most recent Hb

Results
Date

Step 2. Lung Function Referral

Lung Function Referral (Please tick)

Comprehensive Lung Function (spirometry, diffusing capacity and absolute lung volumes)
Full Lung Function (spirometry, diffusing capacity)
Spirometry and bronchodilator response
Forced expiratory nitric oxide testing
Positional spirometry

Does the lung function test require a specialist consultation?

If appropriate, please ask all patients having initial lung function testing at NBST, to withhold all inhaled medications for 12 hours prior testing.

Sleep Referral

Does the patient require a diagnostic sleep study?

Upper airway surgery, positional therapy, appropriate oral appliance, weight loss > 10 % in the last 6 months, oxygen therapy or other therapy.

Sleep service requested

Sleep physician consultation prior to any sleep study
Intervention sleep Study - Note a sleep physician review is required for this to be a Medicare subsidised study.
CPAP titration study
Post upper airway surgery, oral appliance OR >10% weight loss positional therapy