LUNG FUNCTION REQUEST FORM
PATIENT DETAILS
Name:  <PtFullName>	Date of Birth: <PtDoB>	
Address: <PtStreet> <PtCity>  <PtPostcode>		
Medicare: <PtMCNo>  <PtMCLine>		
Phone Number: <PtPhoneMob>   <PtPhoneH>		
CLINICAL INFORMATION

TEST REQUESTED
	  Basic Spirometry		  Comprehensive Lung Function Assessment	
	-	Pre and post-bronchodilator
		-	Pre and post-bronchodilator Spirometry
-	Diffusion Capacity of Carbon Monoxide
-	Body Plethysmography
	
	  Baseline Lung Function Assessment		  Bronchoprovocation Testing	
	-	Pre and post-bronchodilator Spirometry
-	Diffusion Capacity of Carbon Monoxide
		-	Baseline Spirometry*
-	Mannitol Bronchoprovocation
* Please note if baseline FEV1 is <50%, respiratory physician review is required prior to testing.	
	  Airways Assessment			
	-	Pre and post-bronchodilator Spirometry
-	Diffusion Capacity of Carbon Monoxide
-	Fraction of Exhaled Nitric Oxide (FeNO)			

Additional test available on request in addition to above:
	  Maximal inspiratory and expiratory pressures		  FeNO	

Referrer Information:
Requesting Doctor:  <DrName>	Provider No:  <DrProviderNo>	
Address:  <LocationName>  <DrStreet>  <DrCity>  <DrPostcode>	
Signature______________________	
Phone:   <LocationPhone>	 Request Date: <TodaysDate>