Adult and Paediatric Pulmonary Request Form
Patient Information:
Name: ___________________________Date of Birth: __/__/__Gender: _______________
Height: ____________________ Weight: ___________  Phone: _______________________
Smoking history:_____________________Current inhalers:Choose an item.
Reason for Test: Please check all that apply:
☐ Assessment of lung function prior to surgery 		
☐ Evaluation of lung function in patients with respiratory symptoms (cough, wheezing, shortness of breath) 
☐ Assessment of lung function in patients with known lung disease (COPD, asthma, etc.) 
☐ Monitoring of lung function in patients with known lung disease 
☐ Other (please specify): __________________________________________
Test Requested: Please check all that apply:
☐ Spirometry (Pre & Post BD)	 ☐ Diffusion capacity measurement 	☐ Bronchial challenge test (Mannitol)
☐ Fractional exhaled nitric oxide (FeNO) measurement    ☐ 1 Min sit/stand
☐ Other (please specify): __________________________________________
Special Instructions:
Patient should refrain from smoking for at least 6 hours prior to the test. Patient should refrain from using bronchodilators for at least 36 hours prior to the test. Inhalers need to be ceased for 72hrs prior to mannitol
Physician Information:
Name: ________________________________ Provider #________________________________
Clinic/Hospital: _________________________________________________________________
Phone: ________________________________ Fax: ___________________________________
Date of Referral: ___/___/___
Additional Comments/Notes: ________________________________________________________ __________________________________________________________________________________