Central Queensland Hospital and Health Service           

Speciality Referred to: CLINICAL MEASUREMENTS

Phone: 07 4920 6326 Fax: 07 4920 6200
Address: First Floor Medical Block, Rockhampton Hospital,
Canning St, ROCKHAMPTON QLD 4700

Respiratory:
Neurology: Dr T J PHAMNGUYEN M.B.B.S. F.R.A.C.P. 4755081L/ Dr M TAN M.B.B.S. F.R.A.C.P. 223056KK / Dr I WILSON M.B.B.S. F.R.A.C.P. 2627931F		

See Clinical Measurements Referral Requirements for more information at www.health.qld.gov.au/cq/gp/ 
<TodaysDate>	<Practice>	
Dr: <DrFirstName><DrSurname><DrQualifications>	<UsrAddress>	
<DrProviderNo>	Ph: <UsrPhone> Fax: <UsrFax>	

Name: <PtFormalName>	Medicare card: <PtMCNo> / <PtMCLine> / <PtMCExpiry>	
D.O.B.: <PtDoB>                            Sex: <PtSex>	Concession card: <PtPensionNo>	
Address: <PtAddress>	DVA card: <PtDVANo>
Referral validity period: <Referral validity period>	
Phone:   <PtPhoneH>
Mobile: <PtPhoneMob>	If interpreter required indicate language here: <If interpreter required indicate language here:>	

Patient's Medical History	
Smoker <Smoker>                    <SmkStatus>    <SmkHx>
Alcohol <Alcohol>                      <AlcHx>           
DM <Diabetes>	
Family History of Seizure Disorder <Family Hx of Seizure disorder>	
Special Requirements 
Infection/Isolation <Infection/Isolation>     
Bed Bound <Bed Bound>   
Falls Risk <Falls Risk>
Oxygen required <Oxygen Required>       
Other requirements <Other Requirements>
Intellecutal/Physical Disability which can affect compliance with testing
<Any disability that can affect compliance with tests>	
Investigations Requested
EEG Referral Guidelines: 1 Guidance | Epilepsies: diagnosis and management | Guidance | NICE
NEUROLOGICAL	<EEG> EEG (Age 16 + only – refer to Paediatrician for Paediatric EEGs)	
	<EEG (Sleep Deprived) *Must have had a routine EEG first> EEG (Sleep Deprived) *Must have had a routine EEG first 	
	<Nerve Conduction Study (Peripheral Nerves)> Nerve Conduction Study (Peripheral Nerves)	
		
RESPIRATORY	<Pre & Post Spirometry> Spirometry Pre and Post Bronchodilator	
	<Gas Tansfer (DLCO)> Gas Tansfer (DLCO)	
	<Static Lung Volumes> Static Lung Volumes	
	<Complex Lung Function> Complex Lung Function (includes all of the above)	
	<Bronchoprovocation (Mannitol) Must have Pre/Post Spirometry> Bronchoprovocation (Mannitol) *Must have Pre/Post Spirometry prior to Bronchoprovocation	
	<Overnight Pulse Oximetry> Overnight Pulse Oximetry	
	<6 minute Walk Test *must be able to walk +/- aids> 6 minute Walk Test *Must be able to walk independantly with or without a walking aid, test takes up to 1 hour	
Clinical history/Reason for Test: 
<Clinical history/Reason for Tests:>

Signature:

Dr:  <DrFirstName>  <DrSurname>

Office Use ONLY	
Date Referral Received:_______________	

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