Home Sleep Test Patient Referral Form
<<Doctor:Name>> <<Doctor:Qualifications>> 
Provider Number  <<Doctor:Provider Number>>
<<Practice:Name>>
<<Doctor:Address>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>
Phone <<Doctor:Phone>> (All Hours) Fax <<Doctor:Fax>>  e-mail <<Doctor:E-mail>>
<<Miscellaneous:Date>>

Sleep Apnoea NQ
4/30 Bamford Lane
Kirwan QLD 4817
Ph: 0457 191 308
Fax: (07) 4422 0055	Reporting Physcian
Dr Geoffrey Williams
Medisleep
Suite 7&8, 70 River Street
Ballina NSW 2478	

Patient <<Patient Demographics:Full Name>>
D.O.B. <<Patient Demographics:DOB>> Our File No: <<Patient Demographics:Record Number>> Medicare No: <<Patient Demographics:Medicare Number>> Health Insurance <<Patient Demographics:Health Insurance>>
<<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:Postcode>> 
Phone No (home) <<Patient Demographics:Phone (Home)>> Phone No (work)<<Patient Demographics:Phone (Work)>> Phone No (mob) <<Patient Demographics:Phone (Mobile)>>

Sleep Statement

Clinical History
Comorbidities
Hypertension? <<Hypertension>>	Heart Attack - Infarct? <<Heart Attack - Infarct>>	Atrial Fibrillation? <<Atrial Fibrillation>>
Diabetes? <<Diabetes>>	Cardiac Stent or Angioplasty? <<Cardiac stent or angioplasty>>	Respiratory Disease? <<Respiratory Disease>>
Stroke or TIA? <<Stroke of TIA>>	Angina? <<Angina>>	Erectile Dysfunction? <<Erectile Dysfunction>>
Obesity? <<Obesity>>	Arrhythmia? <<Arrhythmia>>	Nocturia? <<Nocturia>>
Dyslipidaemia? <<Dyslipidaemia>>	Cardiovascular Disease? <<Cardiovascular Disease>>	Depression? <<Depression>>

Symptoms
Snoring? <<Snoring>>	Nightime Breathing Disturbances? <<Nightime Breathing Disturbances>>	Witnessed Breathholding? <<Witnessed Breathholding>>
Restless or Broken Sleep? <<Restless or Broken Sleep>>	Frequent Awakenings? <<Frequent Awakenings>>	Morning Dry/Sore Throat? <<Morning Dry/Sore Throat>>
Unrefreshed in a.m? <<Unrefreshed Am>>	Daytime Sleepiness/Fatigue? <<Daytime Fatigue>>	Poor Memory/Concentration? <<Poor Memory Concentration>>
Insomnia? <<Insomnia>>	Drowsy or Sleepy Driving? <<Drowsy or Sleepy Driving>>	Choking/Gasping? <<Choking/Gasping>>
Morning Headaches? <<Morning Headaches>>	Irritability? <<Irritability>>	Other: <<Other>>

Notes:

Please contact patient to arrange sleep monitoring.
Please send us report via mail.

Yours sincerely,

<<Doctor:Name>>