LAUNCESTON
RESPIRATORY & SLEEP CENTRE	Launceston Respiratory
& Sleep Centre
‘The Charles’
112/287 Charles Street
Launceston TAS 7250
Phone: 03 6331 1300
Fax: 03 6334 0260	
Patient Name:		Gender:		
Address:	
	D.O.B:		
Phone: (H)		(M)		
Email:		Medicare No.:		
	
¨	Detailed Lung Function	¨	Consultation Dr Chia - Sleep & Respiratory Physician	
	(Spirometry, gas transfer, lung volumes)			
¨	Spirometry / FeNO	¨	Consultation Dr Keir - Visiting Respiratory Physician	
	(Airway inflammation & function)			
¨	Muscle Strength Assessment	¨	Consultation Dr McCarthy - Visiting Endocrinologist	
	(MSA) (SNIP, MIPS, MEPS, Postural VC)			
	
¨

¨	Ambulatory Sleep Study – please complete the below questionnaires on behalf of the patient
An ESS of less than 8 & a STOP-BANG of less than 4 requires a consultation with Dr Chia to perform a Sleep Study 
Consultation with Dr Chia if clinically required	
¨	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	
	Sitting and talking to someone 	¨	0	¨	1	¨	2	¨	3	
	In a car, while stopped for a few minutes in the traffic	¨	0	¨	1	¨	2	¨	3	
	AND	
¨	STOP-BANG (please tick) a score of 4 or more	
	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			
	Has a BMI of more than 35kg/m2?	¨	Yes	¨	No			
	Aged older than 50-year-old?	¨	Yes	¨	No			
	Has a neck circumference greater than 43cm for a male and 41 cm for female	¨	Yes	¨	No			
	Gender = Male?	¨	Yes	¨	No			
	An ESS of less than 8 and a STOP-BANG of less than 4 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.)	

	
Referring Doctor:		
Address:		
Phone:		Fax:		
Email:		
Signature:		Date:		
Provider No.:		Copy to:		

	
Instructions for Patients Undergoing Lung Function Testing:	
	
Do not use any inhalers on the morning of the testing.
Do not smoke or consume alcohol or caffeine 4 hours prior to testing.
Do not do vigorous exercise within 30mins of testing.
Do not wear tight clothing that may restrict chest and abdominal movement.
Do not eat a large meal within 2 hrs of testing.	
	
Instructions for Patients Undergoing Sleep Study Testing:	
	
Shower and remove all make-up, creams, sunscreens and nail polish.
Wear a top (T-shirt/nightdress) that you are happy to sleep in.
Organise your evening so that you have limited activities to do once you are connected to the monitor.	
	
Please bring your Medicare card for all tests	
Test Explanations	
	
CPET	Cardiopulmonary Exercise Testing. Provides information on exercise capacity, gas exchange, ventilation efficiency and cardiac function during exercise.	
	
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.	
	
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)	
	
6 Minute Walk Test	Assess functional capacity in walk distance and degree of desaturations	
	
ABG	Arterial Blood Gases	
	
	Launceston Respiratory & Sleep Centre
‘The Charles’ Level 1

Directions
Parking for LRSC is available to the rear of the building.
Please enter ‘The Charles’ complex and continue under the overpass and through the tunnel.
Please be aware that this is a Care Park area.