Admin Fax:1800 202 1111300 793 236

Office:

Referral Fax: (03) 8669 4575

Patient Details

Name:

Address:

Date of birth:

Telephone (H):

Telephone (M):

Medicare No:

Weight:

Height:

Referring Doctor Details

Results

Copies toDoctor Signature

Electronic Report Fax Report

Clinical Details

Date

BULK BILLINGAVAILABLE

Suite G1,202 JellsRoad Wheelers HillVic3150PO Box 3551 Wheelers Hill Vic 3150Website: www.heartscope.com.auEmail: info@heartscope.com.au

Heartscope LimitedABN: 29 135 556 204

Services Requested(Tick Service Box In Bottom Section)

Cardiac Services

9. Lung FunctionTest (15 years & older) (Combined Spirometry & Gas Transfer Factor)

Bookings Call: (03) 9560 7558 or 1800 202 111 Fax: (03) 8669 4575

Salveo SPECIALIST MEDICAL CENTRE

Sleep & Respiratory Services Other Services

Dr Rajiv Sharma MBBS, MD, FRACP

Sleep & Respiratory PhysiciansDr Hamna Sahi MBBS, FRACP

Dr Kiran MunnurMBBS, FRACP, PhD

Dr Nizam UddinMBBS, FRACP

Dr Dimuth DeSilva Dr Ali Al-FiadhMBChB, PhD (Uni.Melb),FRACP, FESC, FCSANZ

Dr Ravi IyerMBBS, FRACP

Dr Kon ProfitisMBBS, FRACP

Dr Rafi Huq MBBS (Monash), FRACP, FCSANZ

MBBS, FRACP, FCSANZ

BM BCh, MRCP, FRCS(CTh), FRACS A/Prof Philip Hayward

Dr T H Goh FRACP, DDU, FACCFSCAI, FCSANZ

Dr Ai Vee NgMBBS, FRACP

Dr Pavithra Naidu MBBS, FRACP

General & Non-Invasive Imaging Cardiologists

SyncopyHypertension

CVD

PalpitationsHigh Cholesterol

ArrhythmiaStroke / TIA Diabetes

(Please Tick Appropriate Boxes Below)

11. Sleep Investigation (18 years & older)

10. Sleep & Respiratory Consultation

12. CPAP / Sleep Dental Treatment

1 Epworth Sleepiness Scale

Score = ........................ (min 8)

2 Stop-Bang (min 4) or OSA 50 (min 5)

Score = ............. Score = .............

Home based sleep study (MBS 12250)For suspected sleep apnea. If deemed necessary, a Sleep Physician appointment may be arranged.

Your Doctor has recommended that you use Heartscope. You may choose another provider, but please discuss this with your doctor first.

Appointment Details

Location:...............................................

Time:................. Date:..........................Please bring your Referral form, Medicare card /

DVA card / Concession card & Medications list with you.

* PLEASE TURN PAGE OVER FOR QUESTIONNAIRES

(An appointment with a Sleep Physician will be arranged, who will recommend appropriate CPAP / Sleep Dental Appliance treatment)

Note: Questionnaires - Patient & doctor details must be completed on back of referral for Medicare Bulk-Billing / Rebate which is claimable once per year.

BMI:

* For Home Based Sleep Study, please fax both sides of the referral form to ensure compliance with Medicare

AsthmaChest Pain

Chronic Dyspnea COPD

(Please indicate clinical reasons above)

V1-2020

Dr Chelliah Gnanaharan

SOBBronchitis Chronic Cough Pre-Op

MBBS, FRACP, FCSANZ, ASE

Dr Bhupesh PathikBMedSci, MBBS, FRACP, PhD

Dr Madhu GopalakrishnanMBBS, MD, DM, MBA, FACP, FRACP

Dr Sandeep PrabhuMBBS (Hons), LLB (Hons), FRACP, PhD

S P E C I A L I S T G R O U P

Dr Shahnaz HaqueMBBS, MRCP (UK), FRACP

Interventional Cardiologists Electrophysiologists

Cardiothoracic Surgeon

Dr John Voukelatos MBBS, FRACP

1. Stress Echocardiogram

3. Echocardiogram (TTE)

4. Cardiologist Consultation + CT Coronary Angiogram (CTCA) (Specialist Referral Required For This Procedure)

7. ECG6. 24 hour BP Monitor (Privately Billed)

2. Dobutamine Stress Echo

8. Cardiologist Consultation

5. 24 hour ECG Holter Monitor

(Privately Billed)

Calcium Score Test

GeneralInterventionalArrhythmia Clinic (EP)

For Home Based Sleep Study, please fax both sides of the referral form to ensure

compliance with Medicare

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G1, 202 Jells Rd, Wheelers Hill 3150

Suburb Clinic Name Address SOUTH EAST

Heartscope St. AlbansSt Albans 2 - 4 Collins St, St Albans 3021

Heartscope ThomastownThomastown

NORTH

113 High St, Thomastown 3074

BULK BILLINGAVAILABLE

For Bookings Call: (03) 9560 7558 or 1800 202 111 Fax Referrals to: (03) 8669 4575

EAST

WEST

Heartscope MooroolbarkMooroolbark 25 Manchester Rd, Mooroolbark 3138

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oron

ary

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Heartscope / Marina RadiologyBurwood East 1 Lakeside Dr, Burwood East 3151

Dandenong Heartscope Dandenong 40 Stud Rd, Dandenong 3175

Pakenham Heartscope Pakenham 2 McGregor Rd, Pakenham 3810

Roxburgh Park Specialist CentreRoxburgh Park

Heartscope BalaclavaBalaclava

1 Manley Ave, Roxburgh Park 3064

INNER CITY

336 Carlisle St, Balaclava 3183

Kilmore HospitalKilmore

Moonee Ponds Specialist CentreMoonee Ponds 827 Mt Alexander Rd, Moonee Ponds 3039

Rutledge St, Kilmore 3764

Heartscope Glen WaverleyGlen Waverley L1, Suite 11, 2 Brandon Park Dr, Glen Waverley

La Trobe Private Hospital SuitesBundoora Cnr Plenty Rd & Kingsbury Dv, Bundoora

REGIONAL VICTORIA

Heartscope WerribeeWerribee 245 Heaths Rd, Werribee 3030

SITUATION SCORESitting and reading ---------------------------------------------------------------- Watching TV ------------------------------------------------------------------------ Sitting, inactive in a public place (e.g. theatre or a meeting) ----------- As a passenger in a car for an hour without a break --------------------- Lying down to rest in the afternoon, when circumstances permit ----- Sitting and talking to someone ------------------------------------------------ Sitting quietly after lunch without alcohol ----------------------------------- In a car, while stopped for a few minutes in traffic -----------------------

The Epworth Sleepiness Scale Test (Medicare Pre-Qualification Test) How likely are you to doze off or fall asleep in the situations described, in contrast to feeling just tired?

This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they have affected you. Use the scale test on the left to choose the most appropriate number for each situation.Total = ....................................

0 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 30 1 2 3

Score Result: 0 - 7 = Normal (Bulk billing not applicable)

8 - 24 = Abnormal (Complete questionnaire below)

0 - Would never doze 1 - Slight chance of dozing2 - Moderate chance of dozing3 - High chance of dozing

Do you SNORE loudly (loud enough to be heard through closed doors) ? Do you often feel TIRED, fatigued or sleepy during daytime ? Has anyone OBSERVED you stop breathing or choking during your sleep ? Do you have or are you being treated for high blood PRESSURE ? BMI more than 35kg / m2 ? AGE older than 50 years ? NECK size large (Males: 43cm+ & Females: 41cm+) ? GENDER = male ?

STOP - BANG Sleep Apnea Questionnaire for Patient

Wantirna Heartscope / Marina Radiology 623 Boronia Rd, Wantirna, 3152

Minimum4 Ticks

To Qualify

Doctor:........................................................ Signature:...................................... Date:......................

Berwick Heartscope / Marina Radiology 48 Kangan Dr, Berwick 3806

Burwood Specialist CentreBurwood 367 Warrigal Rd, Burwood 3125

For Sleep Studies please complete questionnaires below: Patient Name:........................................... DOB:..............

Heartscope Caul�eld SouthCaul�eld South Level 1,700 Glenhuntly Rd, Caul�eld South 3162

S P E C I A L I S T G R O U P

Cranbourne Heartscope Cranbourne 24 Mundaring Dr, Cranbourne 3977

OSA 50 Screening QuestionaireTo Qualify for Bulk-Billing a patient must score 5 or more

ObesityWaist Circumference ................. cm ------------------------- = 3(Male > 102cm & Female > 88cm * Waist measurement at the umbilicus level)

Snoring Has your snoring ever bothered other people ---------------- = 3Apneas Has anyone noticed that you stop breathing during sleep ----- = 2Age 50+ Are you aged 50 years or over ? ------------------------------ = 2

Please Circle

Total Score ............. / 10

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