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(905) 848-8686
(905) 848-8796
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Referral Form
DR HAMMAD RAFAY
DR LANDMAN
Dr. Hammad Rafay
Home
Dr. Hammad Rafay
Referral Form Respirology and sleep Medicine
DR HAMMAD RAFAY
Call: (905) 848-8686 | Fax: (905) 848-8796
FRCPC, DRCPSC
Address: 720 Burnhamthorpe Rd W Unit# 4 Mississauga ON L5C 3G1
Referral Date
Booking Urgency
Routine
Urgent
PAITENT INFORMATION
Date Of Birth
Gender
Male
Female
Preferred Not To Answer
REASON FOR REFERAL:
Dyspnea
Yes
No
Asthma
Yes
No
Cough
Yes
No
COPD
Yes
No
Lung Mass
Yes
No
Infection/TB/NTM
Yes
No
Abnormal chest imaging
Yes
No
Interstitial lung disease/fibrosis
Yes
No
INCLUDE WITH REFERRAL
Past medical history & medication
TB skin test/GRA (if applicable)
Relevant consultation reports & investigations
Recent labs/bloodwork
Previous spirometry/PFT, sleep studies (if applicable)
Chest and/or other relevant image results
REFERRING PHYSICIAN INFORMATION
Physician Contact
Physician Signature
Phone
Alternate Contact
Sleep Medicine:
Symptoms:
Snoring
Yes
No
Witnessed apnea
Yes
No
Excessive daytime sleepiness
Yes
No
Difficulty initiating/maintaining sleep
Yes
No
Restless legs
Yes
No
Abnormal nocturnal movement/behaviors
Yes
No
Working Diagnosis:
Sleep Apnea
Yes
No
Insomnia
Yes
No
Narcolepsy
Yes
No
PLS/PLM
Yes
No
Parasomnia
Yes
No
CPAP reassessment
Yes
No
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