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Referral To Sleep Physician – THE SLEEPHEALTH CLINIC
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Hi, welcome to qoctor. You will now undergo an assessment regarding your sleep. Based on the results, you will be referred to a sleep specialist for further investigations.
Screening Questionnaire
Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
*
Yes
No
Do you often feel tired or sleepy during the daytime?
*
Yes
No
Has anyone observe you stop breathing during your sleep?
*
Yes
No
Do you have high blood pressure, or are you on medication for high blood pressure?
*
Yes
No
Is your BMI (body mass index) more than 35kg/m2?
*
Quick BMI calculator to assist
Height (m)
Weight (kg)
=
Yes
No
Are you aged over 50 years old?
*
Yes
No
Is your neck circumference ( measurement around your neck) more than 40cm/ 16 inches?
*
Yes
No
Are you male?
*
Yes
No
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
It is important that you answer each question as best you can.
Sitting and reading
0
1
2
3
Watching TV
0
1
2
3
As a passenger in a car for an hour without a break
0
1
2
3
Sitting, inactive in a public place (e.g. a theatre or a meeting)
0
1
2
3
Lying down to rest in the afternoon when circumstances permit
0
1
2
3
Sitting and talking to someone
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
Specialists Details
Please select the physician/clinic you wish to attend from the menu :
The SleepHealth Clinic
Other
Would you like us to email your referral letter directly to the above specialist today?
Yes, send to my specialist and to me
No thanks, just email it to me
Specialist Name
*
Specialist Address
*
Specialist Telephone Number
*
Specialist Fax Number
*
GP's Details
GP's Name
*
GP's Address
*
GP's Telephone Number
*
GP's Fax Number
*
To complete your specialist referral letter , we need to obtain your medical history
Please select any conditions from the following list that apply to you now, or have applied to you in the past (leave blank if none apply)
Hypertension ( high blood pressure)
Heart disease
Stroke
Asthma
Thyroid disorder
Type 1 Diabetes
Type 2 Diabetes
Anxiety/depression
Epilepsy
Liver disease
Migraine (diagnosed by a doctor)
Cancer
Blood clots
Arthritis
Smoker
Other
We also need to know about any surgical history. Have you had any surgery in the past?
*
Yes
No
Please select any of the following that apply to you:
Appendicectomy
Heart Surgery
Bowel Surgery
Tonsillectomy
Gynaecological surgery
Weight loss surgery
Gallbladder surgery
Prostate surgery
Other
Have you had any allergies or bad reactions to any of the following medications?
Penicillins
Sulpha drugs
Antibiotics other than penicillin/sulpha drugs
Anti-inflammatories
Codeine
Morphine or morphine related medications
Other
I agree to provide an up-to-date list of all my medications to my specialist when I attend for my appointment
*
Yes
No
I understand that if at any point I experience chest pain, chest tightness or shortness of breath, I should seek urgent medical attention.
*
Yes
No
Please confirm all the following apply to you
*
○ I am 18 years old or over.
○ This referral is to be used only by me or my child, for whom I have legal responsibility
○ I confirm that all correspondence will go to my current GP
○ I confirm that it may take several months to see a specialist, and if my condition gets worse I will see my regular doctor
○ I am aware there may be some out of pocket costs and will discuss this with my specialist
○ I agree to the terms and conditions of use
Yes
No
thank you for completing this questionnaire- please click NEXT below to continue your booking
Please select a Video consultation or Phone Consultation
*
Phone Consultation
Video consultation
Please enter your Phone number
*
Confirm your phone number
*
Please complete payment and then choose your appointment time.
The following times are available to book a consultation.
Please complete the following steps:
Purchase the consultation from the shopping cart
Select and confirm your telehealth consultation time
Click on the sms or email link 15 minutes prior to the start of your consultation time
The doctor will call you on the video link during your chosen time slot
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