Dubbo Hospital
Department of Respiratory Medicine
170 Myall St DUBBO NSW 2830
Respiratory Physiology – Richard Hawksworth
Phone:  (02)6809 6097  Fax: (02) 6809 7270
ARGUS: WNSWLHD-ccdubsmc@health.nsw.gov.au		
Respiratory Physician: <Respiratory Physician Patient would like to see?>

External Referral
Doctors Name: <DrName>	Patient Name: <PtName>                                                  Sex: <PtSex>	
Doctors Address:<UsrAddress>	Patient Address: <PtAddress>	
Phone: <UsrPhone>                             
Fax: <UsrFax>	Patient DOB: <PtDoB>	
Doctors Provider No: <DrProviderNo>	Patient Home Phone: <PtPhoneH>
Patient Mobile: <PtPhoneMob>	
Signature: 	Appt Required:   First Available: <Appointment Required: First Available?>	
Date: <TodaysDate>	or before Next appointment on: <or before next appointment on >	

Clinical Details:
<PMHActive>

Reason for Test: 
<Reason for Test?>

Spirometry:     <Spirometry required?> 	Transfer Factor: <Transfer Factor?>
Hb <How much Hb________ g/dl?> g/dl	Lung Volumes: <Lung Volumes?>	

Contraindications to Lung Function Testing:
<Inability to understand instructions?>    Inability to understand instructions?	<Myocardinal infarct within 2 weeks?>    Myocardial infarct within 2 weeks	
<Current URTI?>    Current URTI	<Major Abdominal / Thoracic Surgery within 4weeks>    Major Abdominal / Thoracic Surgery within 4 weeks	
<Exacerbation of Respiratory Disease within 6weeks>    Exacerbation of Respiratory Disease within 6 weeks	<Pneumothorax within 2 weeks?>    Pneumothorax within 2 weeks	

Internal Use only 
Skin prick Test    		Sleep Apnoea Screening		
Bronchodilator Studies		Exercise Testing (6 MWT / ISWT)		
Asthma Provocation 		Fitness to Fly		
Respiratory Muscle Strength