NHS e-Referral Service
Respiratory/Sleep Physiology Test request form
SECTION 1: PATIENT DEMOGRAPHIC DETAILS
Patient NHS number:
UBRN:
Patient first name(s):
Patient last name:
Date of Birth (DD/MM/YY):
Gender:
Male
Female
Patient address (1st line):
Patient town / city:
Patient postcode:
Patient contact number:
Patient contact number 2:
SECTION 2: REFERRER INFORMATION
First name:
Last name:
Referrer role:
GP
On behalf of GP
GP Practice Code:
Referrer contact no:
GMC Registration No:
Referrer e-mail address:
SECTION 3: CLINICAL HISTORY
Infection risk (MRSA or TB)?
No
Yes
In the last six weeks has the patient had:
History of ischaemic heart disease?
No
Yes
Myocardial infarction?
No
Yes
History of diabetes?
No
Yes
Abdominal, chest or eye surgery
No
Yes
History of TIA / stroke?
No
Yes
Pneumothorax?
No
Yes
Able to walk unaided?
No
Yes
Chest infection?
No
Yes
Aortic aneurysm?
No
Yes
Medication – Inhalers?
No
Yes
Medication - B-blockers?
No
Yes
Pack years of smoking
___ years
Medication - Other relevant?
SECTION 4: TEST REQUEST DETAILS
Reason for request:
Provisional diagnosis (or key symptoms and signs):
4A) FOR RESPIRATORY TESTS:
1. Spirometry with bronchodilator (if FEV1 < 70% pred AND FEV1/ FVC ratio < 70%)
2. Full lung function tests ( spirometry, volumes and gas transfer)
3. Blood Gas Analysis (only if oximetry = 92% or below)
Is your patient already on home oxygen therapy (SBOT, AOT, LTOT)?
No
Yes
___ Flow
___ Hours
4. Assessment of Long Term Oxygen Therapy (LTOT)
(N.B. If on second blood gas sample, patients do not meet LTOT criteria they will be rebooked for gases at
3 months)
5. Assessment for ambulatory oxygen therapy if already on LTOT
(N.B. Ambulatory oxygen assessment will take place as per Department of Health guidelines)
4B) FOR SLEEP TESTS
6. Overnight Oximetry/ Sleep Apnoea Screening
7. Assessment if CPAP acceptable for patient
(N.B. Two week trial of home use after diagnosis confirmed)
Please answer the following questions for patients requiring sleep tests:
Body Mass Index (Wt (kg) / Ht (m) 2
______
Witnessed apnoeas?
No
Yes
Snoring?
No
Yes
Driver?
No
Yes
Is the individual excessively sleepy?
No
Yes
Epworth score >11? (see attached sheet)
No
Yes
Standard licence
HGV / PSV
The Epworth Sleepiness Scale (for patients)
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your
usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would
have affected you.
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
Score
Situation
Sitting and reading
Watching television
Sitting inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few moments in traffic