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reception@swcpc.com.au
Suite 2.12, 90 Podium Way, Oran Park New South Wales 2570, Australia
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Our Team
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Sherwin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home-Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Information
Patients Resources
Practitioner Resources
Contact Us
Menu
Home
Our Team
Dr Saurabh Gupta
Dr Haider Naqvi
Dr Sherwin Amirmalek
Dr Michelle Donegan
Shondell Tilden
Services
Respiratory
Respiratory Function Testing
Sleep
Home-Based Sleep Studies
Mandibular Advancement Splint (MAS) Consultation
Information
Patients Resources
Practitioner Resources
Contact Us
Request a call
(02) 4607 5010
Southwest Pulmonary & Sleep Centre Referral Form
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Please enable JavaScript in your browser to complete this form.
Patient Name
*
Date of Birth
Mobile
Address
Address Line 1
City
State / Province / Region
Postal Code
Referral
Appointment
Respiratory Appointment
Sleep Appointment
Lung Function Test
Sleep Study (Stop Bang ≥4 AND ESS ≥8)
Physician
Dr Saurabh Gupta
Dr Haider Naqvi
First Available Appointment
Medical History
Cardiovascular Disease
Hypertension
Stroke
Diabetes
Atrial Fibrillation
Sleep Apnoea
Symptoms
Snoring
Restless Legs
Cough / Wheeze
Witnessed Apnoea
Shortness of Breath / Daytime Sleepiness
STOP BANG Questionnaire
Yes = 1
Does the patient Snore loudly?
Yes
No
Does the patient often feel Tired, fatigued, or sleepy during the daytime?
Yes
No
Has anyone Observed the patient stop breathing during sleep?
Yes
No
Does the patient have, or is being treated for high blood Pressure?
Yes
No
Does the patient have a BMI more than 35kg?
Yes
No
Is the patients Age over 50 years old?
Yes
No
Is the patients Gender male?
Yes
No
TOTAL SCORE
ESS Questionnaire
How likely are you to doze off in these situations?
Never = 0
Slight = 1
Moderate = 2
High = 3
Sitting and reading
Selected Value:
0
Sitting, inactive in a public place
Selected Value:
0
Sitting and talking to someone
Selected Value:
0
As a passenger in a car for an hour without a break
Selected Value:
0
Lying down to rest in the afternoon when circumstances permit
Selected Value:
0
Watching television
Selected Value:
0
Sitting quietly after lunch without alcohol
Selected Value:
0
In a car, stopped for a few minutes in the traffic
Selected Value:
0
TOTAL SCORE
Referrer
Referring Doctor
*
Provider Number
Address
Address Line 1
City
State / Province / Region
Postal Code
Phone
Healthlink EDI
In the to
Signature Stamp
Type in name for signature
Date
Submit
Southwest Pulminary & Sleep Centre
4.8
Based on 4 reviews
Southwest Pulminary & Sleep Centre
4.8
review us on
See all reviews
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Toni Maree Cook
1677452837
Fabulous Drs and staff, so friendly I was made to feel at ease.
Harvinder Singh
1664153935
Dr Haider spends good amount of time with the patients and explains everything properly.
Indy Darmanin
1659668247
DINESH GOYAL
1642504811
I got the treatment very nice and dr were also very friendly and good behaviour. There charges are also very nice.
