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/ 

<<Miscellaneous:Date>>	<<Practice:Name>>	
Dr: <<Doctor:Name>> <<Doctor:Qualifications>>	<<Practice:Address>>	
<<Doctor:Provider Number>>	Ph: <<Practice:Phone>> Fax: <<Practice:Fax>>	

Name: <<Patient Demographics:Full Name>>	 Medicare card: <<Patient Demographics:Medicare Number>>   <<Patient Demographics:Medicare Expiry Date>>	
D.O.B.: <<Patient Demographics:DOB>>        Sex: <<Patient Demographics:Gender>>	Concession Card: <<Patient Demographics:Pension Number>>	
Address: <<Patient Demographics:Address>>	DVA card:  <<Patient Demographics:DVA Number>> 
Referral validity period:  <<Referral validity period>>	
Phone:  <<Patient Demographics:Phone (Home)>>
Mobile:  <<Patient Demographics:Phone (Mobile)>>	If interpreter required indicate language here:  <<If interpreter required indicate language here>>  	

Patient's Medical History	
Smoker: <<Smoker>>                <<Clinical Details:Smoking>>
Alcohol: <<Alcohol>>                    <<Clinical Details:Alcohol>>
DM: <<Diabetes>>	
Family History of Seizure Disorder: <<Family Hx of seizure disorder>>	
Special Requirements <<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 <<Investigations Requested>>
EEG Referral Guidelines: https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#investigations
NEUROLOGICAL	EEG (Age 16+ only – refer to Paediatrician for Paediatric EEGs): <<EEG>>	
	EEG (Sleep Deprived) *Must have had a routine EEG first: <<EEG (Sleep Deprived) *Must have routine EEG 1st>>	
	Nerve Conduction Study (Peripheral Nerves): <<Nerve Conduction Study (Peripheral Nerves)>>	
		
RESPIRATORY	Spirometry Pre and Post Bronchodilator: <<Spirometry Pre and Post Bronchodilator: >>	
	Gas Transfer (DLCO): <<Gas Transfer (DLCO)>>	
	Static Lung Volumes: <<Static Lung Volumes>>	
	Complex Lung Function (includes all of the above): <<Complex Lung Function (includes all of the above)>>	
	Bronchoprovocation (Mannitol) *Must have Pre/Post Spirometry Prior to Bronchoprovocation: <<Bronchoprovocation (Mannitol)>>	
	Overnight Pulse Oximetry: <<Overnight Pulse Oximetry>>	
	6 minute Walk Test *Must be able to walk independently with or without a walking aid, test takes up to 1 hour: <<6 minute Walk Test *must be able to walk +/- aids>>	
Clinical history/Reason for Test: <<Clinical history/Reason for Test>>

Signature:

Dr:  <<Doctor:Name>>

Office Use ONLY	
Date Referral Received:_______________	

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