Patient Name:	<<Patient Demographics:Full Name>>	
Address:	<<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
Home Phone:	<<Patient Demographics:Phone (Home)>>	Mobile Phone:	<<Patient Demographics:Phone (Mobile)>>	
Email:	<<Patient Demographics:E-mail>>	
D.O.B:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>	
Medicare No:	<<Patient Demographics:Medicare Number>>	

Please perform the following:	
¨	Detailed Lung Function	¨	Consultation Dr Chia 	
	(Spirometry, gas transfer, lung volumes)		Sleep & Respiratory Physician	
¨	Spirometry / FeNO	¨	NW Sleep Study	
	(Airway inflammation & function)			
¨	Muscle Strength Assessment	¨	Consultation Dr McCarthy 	
	(MSA) (SNIP, MIPS, MEPS, Postural VC)		Visiting Endocrinologist	

¨	Ambulatory Sleep Study and Dr Chia Consultation (*recommended)	
¨	Ambulatory Sleep Study	PLEASE COMPLETE QUESTIONS ON NEXT PAGE	
	An ESS of less than 8 and a STOP-BANG of less than 3 requires a consultation with Dr Chia prior to performing a Sleep Study	

Clinical History - (please include medications and any special requirements e.g. reduced mobility etc)	
<<Clinical Details:Medication List>>	

Referring Doctor:	<<Doctor:Name>>	Provider No:	<<Doctor:Provider Number>>	
Address:	<<Practice/Location:Address>>	Signature:	

Phone:	
<<Practice/Location:Phone>>	

Email:	<<Practice/Location:E-mail>>	Fax:	<<Practice/Location:Fax>>	

AMBULATORY SLEEP STUDY – please complete the questionnaires below with patient

¨	Daytime tiredness/ naps	¨	Apnoea’s	¨	Gasping/snorting/gaging arousal	¨	Snoring	
¨	Cardiac history	¨	Unrefreshing sleep	¨	Driving impairment	¨	COPD	
ESS  0 = would never doze off  1 = slight chance of dosing off  2 = moderate chance of dosing off  3 = high chance of dosing off	
Sitting and reading	¨	0	¨	1	¨	2	¨	3	
Watching TV	¨	0	¨	1	¨	2	¨	3	
Sitting inactive in a public place (e.g. a theatre or meeting)	¨	0	¨	1	¨	2	¨	3	
As a passenger in a car for an hour without a break	¨	0	¨	1	¨	2	¨	3	
Lying down to rest in the afternoon when circumstances permit	¨	0	¨	1	¨	2	¨	3	
Sitting quietly after a lunch without alcohol	¨	0	¨	1	¨	2	¨	3	
In a car, while stopped for a few minutes in the traffic	¨	0	¨	1	¨	2	¨	3	
STOP-BANG (please tick)	
Do you snore loudly (louder than talking or can be heard through closed doors)	¨	Yes	¨	No	
Do you often feel tired, fatigued, or sleep during the daytime?	¨	Yes	¨	No	
Has anyone observed you stop breathing during your sleep	¨	Yes	¨	No	
Do you have (or are you being treated for) high blood pressure	¨	Yes	¨	No	
BMI of more than 35kg/m2?	¨	Yes	¨	No	
Older than 50-years-old?	¨	Yes	¨	No	
Neck circumference greater than 43cm for a male or 41 cm for female	¨	Yes	¨	No	
Male Gender	¨	Yes	¨	No	
* pre sleep consultation to meet PBS requirements or to follow up obstructive sleep apnoea patients	

Test Explanations	
Detailed Lung Function	(i) Dynamic Lung Function   (ii) Static Lung Function   (iii) Gas Transfer	
FeNO Exhaled	Biomarker for Eosinophilic airway inflammation. Potential for airway disease evaluation.
Assessments are offered seasonally to establish asthma patterns.	
MSA	MEP - Maximal Exhaled Pressures (maximum pressure generated during sharp exhalation)
SNIP - Sniff Nasal Inspiratory Pressure
MIP - Maximal Inhaled Pressures (maximum pressure generated during sharp inhalation)
VC – Vital Capacity (postural changes may indicate muscle weakness)	
ABG	Arterial Blood Gases	
Sleep Study	Home-based sleep study	

	Launceston Respiratory & Sleep Centre
Level 1, ‘The Charles’ Level 1
112/287 Charles Street
Launceston
Directions
Enter ‘The Charles’ complex from Frankland Street. Continue up the hill past the hotel reception, under the overpass and through the car park. LRSC is located on your right as you drive through the car park. When you reach the end of the complex, turn right to find the patient parking.
Please be aware that this is a Care Park area and you should only park in spaces marked for use by Launceston Respiratory & Sleep Centre.