Lung Function Request

Appointment Details

Date

Time


Patient Details

Name

Phone

D.O.B

Sex
MaleFemale

Address


Investigations

Spirometry (Pre and Post Bronchodilator)
Diffusing Capacity (DLCO)

Bronchial provocation test
Mannitol challenge
MIPS/MES - respiratory muscle strength


Requesting Doctor Details

Name

Provider Number

Address

Copy results to

Date


Clinical Notes

Clinical question (reason for test)

History

Smoker
YesNoEx

Medications

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