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

		
See Clinical Measurements Referral Requirements for more information at www.health.qld.gov.au/cq/gp/ 

Date: 	Practice name: 	
Dr: 	Address: 	
Provider number:	Ph:                           Fax: 	

Patient name: 	 Medicare card:   	
D.O.B.:                Sex: 	Concession Card: 	
Address: 	DVA card:  
Referral validity period:  	
Phone:                      Mobile:  	If interpreter required indicate language here:   	

Patient's Medical History	
Smoking:                
Alcohol:                    
DM: 	
Family History of Seizure Disorder: 	
Special Requirements 
Infection/Isolation:  P:\CDM\ATSI\ - CUSTOM#|L|||6|Yes|No
Bed Bound:  
Falls Risk:          
Oxygen required:      
Other requirements: 
Intellectual / Physical Disability which can affect compliance with testing: 	

Investigations Requested 
EEG Referral Guidelines: https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#investigations

NEUROLOGICAL 
(>16 ages only)	EEG (Age 16+ only – refer to Paediatrician for Paediatric EEGs): 	
	EEG (Sleep Deprived) *Must have had a routine EEG first: 	
	Nerve Conduction Study (Peripheral Nerves) please select below: 
    Carpal Tunnel studies
    Ulnar Neuropathy studies
    Peripheral Neuropathy Screen	

PAEDIATRIC RESPIRATORY (<16 age)

RESPIRATORY (>16)	
Spirometry Pre and Post Bronchodilator:

Spirometry Pre and Post Bronchodilator: 	
	Gas Transfer (DLCO): 	
	Static Lung Volumes: 	
	Complex Lung Function (includes all of the above): 	
	Bronchoprovocation (Mannitol) *Must have Pre/Post Spirometry Prior to Bronchoprovocation: 	
	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: 	
Clinical history/Reason for Test: 

Signature:

Dr:  

Office Use ONLY	
Date Referral Received:_______________	

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