Respiratory Function Request

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Patient Name

First

Last

Date of Birth

Address

Address Line 1

City

State / Province / Region

Postal Code

Phone

Clinical History

Smoking History

Never
Ex-smoker
Current

Required Fax known)

Haemoglobin (g/L - if known)

Tests Required

Full lung function (Spirometry with pre & post bronchodilator/ DLCO/ Lung Volumes)
Spirometry (pre & post bronchodilator)
Mannitol Challenge Test (Bronchial Provocation Test)
MIPs & MEPs (Tests of Respiratory Muscle Function)

Please withhold any puffers on the day of testing – See instructions on the reverse side of page

Referring Doctor/ Stamp

Referring Doctor

Provider Number

Date

Address

Phone

Fax

Lung Function Test Instructions:

Please read the following specific instructions to prepare for your lung function test:
All patients are asked to refrain from the following before their test –
• Smoking (1 hour)
• Performing vigorous exercise (1 hour)
• Consuming alcohol or caffeinated drinks (4 hours)