Download BOC Sleepcare Referral Form

South Eastern
Private Hospital
LIEGE AVE
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TLIN
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W
GH
HI
ES
HEATHERTON RD
RYDER ST
We are here
DAVIS RD
→→ Sleep apnoea pillows
Sleep and
Respiratory
Accessories
SAYERS RD
D
BV
→→ Portable oxygen concentrators
→→ Asthma & aerosol equipment
Tarneit Family Medical and Dental Centre
939 Sayers Road, Tarneit VIC 3029
D
ER
AL
EV
O
Coolaroo
SC
PA
Railway
Station
Progress Reserve
DC
We are here
S
RE
WESTMERE
CRES
The Coolaroo Clinic
Rest assured with BOC Sleepcare
BLAIR ST
EMERAL
D ST
BARRY RD
Gibb
Reserve
510-512 Barry Road, Coolaroo VIC 3048
Email: [email protected]
Fax: 03 9544 7088
To arrange an appointment please call us
on 1300 732 695 or for more information visit
our website www.bocsleepcare.com.au
BOC is a trading name of BOC Limited, a member of The Linde Group.
© BOC Limited 2014. BOC Limited ABN 95 000 029 729, BOC Healthcare
10 Julius Ave, North Ryde NSW 2113, [email protected]
www.bocsleepcare.com.au
* Rebate applicable on selected equipment purchases within the six week trial period.
Not valid with any other offers.
VIC HMD064 EQU 0614 V1 1k
A qualified BOC
Sleep therapist will
monitor your sleep
therapy and provide
ongoing support
and advice to help
you achieve a good
night’s rest.
→→ Sleep positional devices
→→ Other respiratory accessories
OR
GF
4
$250
BOC Sleepcare offers a 6 week CPAP
trial. Our trial includes a machine, mask
and consumables along with advice
and support from our qualified Sleep
therapists every step of the way. Rebates
are available upon purchase*. Contact
us for more information.
Cnr Princes Highway & Heatherton Road, Noble Park VIC 3174
N
LO
If your sleep
study results are
positive you may
be recommended
to initiate a CPAP
trial. CPAP is the
most commonly
recommended form
of Sleep therapy.
Contact BOC
Sleepcare for more
information.
Trial
CPAP for
South Eastern Private
PAPILLION PDE
3
Trial CPAP for $250* (incl GST)
Oakwood
Park
M
BUTTER F LY
Our friendly Sleepcare
team will contact you
to advise when your
results are available.
Alternatively if you
have any questions
regarding your sleep
diagnostic test please
do not hesitate to
contact BOC Sleepcare
on 1300 732 695.
We are here
RD
NC
2
LL
HA
S
AR
I
PR
You can see your
referring doctor
a few weeks
after your sleep
diagnostic test to
review your sleep
study results.
lo
ca
tio
n
1
BOC Sleepcare Offer
Visit your nearest
BOC Sleepcare Centre
ne
w
What happens next?
BOC Sleepcare
1300 732 695
bocsleepcare.com.au
BOC: Living healthcare
BOC Sleep Referral Form
Original
Date: /
Patient Details
Doctor’s Details
Name: Name: Address: Address: Phone: /
How common is OSA?
Obstructive sleep apnoea (OSA) is a common medical
condition. It affects about 1 in 20 adults. It is most common in
middle-aged men, in fact 1 in 10 men aged 45 years or over
have this medical condition. It also frequently occurs in women
aged 65 and over.
(Valid for 12 months from date of referral)
What are the warning signs?
If you have OSA you may not be aware that you stop breathing
while you are sleeping. Quite often, it will be your partner,
family or friends who notice the symptoms first. Some common
symptoms may include:
Postcode: Fax: Postcode: Phone: Signature:
Mobile: DOB: /
/
→→ Waking up in the morning with headaches
→→ Memory or learning problems and not being able to
concentrate
→→ Feeling irritable, depressed, or having mood swings or
personality changes
→→ Fall asleep while working, reading, or watching TV
→→ Feel sleepy while driving, or even fall asleep while driving
→→ Waking up frequently to urinate
→→ Dry mouth or sore throat when you wake up.
Provider No: Please stamp if available:
(please circle)
Commercial Licence (if applicable):
Gender:
YES / NO
MALE / FEMALE
How is OSA diagnosed?
Type of Study
Hospital Diagnostic Sleep Study - Privately Insured / DVA patients
The good news is that OSA can be diagnosed and managed
by your doctor.
Home Diagnostic Sleep Study - Uninsured patients
Successful treatment can improve your sleep, reduce daytime
drowsiness, and improve your quality of life. It can also lower
your blood pressure and improve your heart health.
Please complete on behalf of patient
Do you often feel tired, fatigued
or sleepy during the day?
Has anyone noticed you stop
breathing during your sleep?
Do you have or are you being
treated for high blood pressure?
YES / NO
YES / NO
YES / NO
YES / NO
Reference: STOP Questionnaire (Chung F et al, Anaesthesiology. May
2008; 108(5):812-21).
Overweight/obesity
CCF
IHD
Pacemaker
A sleep study can be carried out in either a Hospital sleep
laboratory or in the comfort of your home. Your doctor will
explain how this can be done. The severity of your OSA will be
measured using a scale called the apnoea hypopnoea index (AHI).
Type of Study (please tick)
What are the treatment
options for OSA?
Home sleep study
Titration review
CPAP Trial
Standard CPAP
Bi-level trial
(no titration needed)
Recommendations
Patients answering YES to 2 or more of the above questions
are at high risk of having OSA and should be referred directly
for an at home sleep study. Patients answering YES to less than
2 questions should be referred to a sleep specialist consultation in order
to determine the necessity for further investigation.
Nasal/sinus
Atrial fibrillation
COPD
Type II diabetes
TIA/CVA
There are a number of different treatments for OSA.
Once your doctor has the results of your sleep study,
they will be able to talk to you about the best options
for your condition.
Relevant Clinical History/Medications (please complete):
Tear here
Do you snore loudly (louder than
talking/can be heard through a closed door)?
OSA can range from mild to severe and may not always need
treatment. Before any treatment is considered, your doctor
will organise a sleep study to work out how severe your OSA is.
Relevant Medical Conditions (please tick)
STOP Questionnaire (please circle)
The most common treatment in Continuous Positive Airway
Pressure (CPAP). The CPAP device provides a gentle flow
of air to keep your airway open while you are sleeping,
preventing pauses in breathing.
What happens now?
1
A doctor
uses sleep
questionnaires
to identify high
risk patients.
2
Patients will be
referred to a BOC
Sleepcare Centre for
a Home sleep study.
3
A BOC Sleep
Therapist will
educate and set
the patient up with
sleep diagnostic
equipment.
4
The results from the
sleep diagnostic
test are sent to a
Sleep Physician
for diagnosis
and treatment
recommendations.
The sleep study
results are then
sent back to your
referring doctor.