Preferred Location:

  ⃣   Balwyn North	  ⃣ Ferntree Gully	  ⃣  Wantirna	
345 Doncaster Road, 
Balwyn North, VIC 3104
	719 Burwood Hwy,
Ferntree Gully, VIC 3156	Suite 2a Knox Private Hospital,
262 Mountain Hwy, Wantirna,VIC 3152 	
  Patient details or label:

  Name:	

DOB:     /	 /	

Phone:		

Lung Function Test	Sleep Study	
Test Requested:
⃣ Spirometry Pre +/- Post Bronchodilator
⃣  Gas Transfer	        ⃣  MIPS/MEPS
⃣  FeNO	        ⃣  6 Minute Walk Test
⃣  Lung Volumes (Plethysmography)
⃣ Oxygen Assessment (Apply for Oxygen Supplementation)
⃣  Bronchial Provocation Test (Mannitol)
⃣ Exercise Challenge Test
⃣ CPET (Cardiopulmonary Exercise Test)
  Clinical Notes:

	Symptoms:
⃣  Snoring
⃣  Witnessed Apnoea
⃣   Excessive Daytime                           Sleepiness
⃣   Waking Unrefreshed
⃣   Nocturia
⃣   Morning Headache
⃣   High STOP-BANG
	Other Medical Conditions:
⃣  Neurologic / Stroke / TIA
⃣  Cardiac Failure / AF / AMI
⃣  Diabetes Mellitus
⃣   Hypertension
⃣  Obesity
⃣  COPD
⃣  Psychiatric Disorder
⃣  Preoperative Assessment	
	Bulk Billing CPAP	
	⃣  Bulk Billing CPAP Clinic	
Lung Cancer Screening Program	
   
     ⃣   Low Dose Non Contrast CT Scan of Chest for Lung Cancer Screening (MBS Item No 57410)

⃣   MDM Meeting	
 Consultation	
  Indication:	
Referring doctor:	Date:	/	/	
Signature:	Provider No:	
CC:	

The following questions should be answered by patients:

STOP-BANG Sleep Questionnaire (For Sleep Patients)
1.	Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)?
 Yes  No
2.	Do you often feel TIRED, fatigued, or sleepy during daytime?  Yes  No
3.	Has anyone OBSERVED you stop breathing during your sleep?  Yes  No
4.	Do you have or are you being treated for high blood PRESSURE?  Yes  No
5.	BMI more than 35kg/m2?  Yes  No
6.	AGE over 50 years old?  Yes  No
7.	NECK circumference > 16 inches (40cm)?  Yes  No
8.	GENDER: Male?  Yes  No

  Number of yes: ………
	Epworth Sleepiness Scale (For Sleep Patients)
0: No chance of dozing 1: Slight chance of dozing
2: Moderate chance of dozing 3: High chance of dozing

1.	Sitting and reading:  0  1  2  3
2.	Watching TV:  0  1  2  3
3.	Sitting inactive in a public place
(e.g. a theatre of meeting):  0  1  2  3
4.	As a passenger in a car for an hour without a break:  0  1  2  3
5.	Lying down to rest in the afternoon when circumstances permit:  0  1  2  3
6.	Sitting and talking to someone:  0  1  2  3
7.	Sitting quietly after a lunch without alcohol:  0  1  2  3
8.	In a car, while stopped for a few minutes in traffic:  0  1  2  3
9.	Are you using MAS/CPAP device while sleeping?  Yes  No

Total Score: ………

                     Lung Care (For Lung Cancer Screening Program)

1.	Age: 50-70 years old?  Yes  No
2.	Any Symptoms (such as cough, sputum, shortness of breath, chest pain, or weight loss)?  Yes  No
3.	Current Smoker?  Yes  No
4.	If you stopped smoking, did you stop less than 10 years ago?  Yes  No
5.	Packsmeter (Pack-Years)?  Yes  No

Number of Yes: ……….                                              Scan for packs-meter calculator  ►