CQRD Lung Function Form – CQ Respiratory Diagnostics

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Name*

DOB*

Address*

Home Ph*

Work*

Mobile*

Clinical History/Details*

Investigation Required*

Full Lung Function (Flow Volume Loops - before and after bronchodilator, Lung Volumes + Gas Transfer).

Flow Volume Loops - before and after bronchodilator.

Bronchial Provocation.(‘Mannitol Challenge)

Respiratory Muscle Strength (MIPS/MEPS & Postural Spirometry).

Six Minute Walk Test (single trial without 02).

Six Minute Walk Test (dual trial without and with 02 for MASS evaluation).

Exhaled Nitric Oxide - FeNO.

Doctors Name*

Address*

Signature*

Provider No*

Date of Referral*

Fax No. for Report*

Copy of Report*

Accepted file types: jpg, pdf, png, Max. file size: 64 MB.

Date*

Withhold Time	Mannitol, Hypertonic Saline, Histamine
8 Hours	Ventolin, Asmol, Bricanyl, Intal, Tilade
12 Hours	Alvesco, Atrovent, Flixotide, Pulmicort, Qvar
24 Hours	Foradile, Nuelin, Oxis, Seretide, Serevent, Symbicort, Theodur
48 Hours
72 Hours	Spiriva, Onbrez, Seebri, Ultibro, Bretaris. Antihistamines Zyrtec, Telfast, Claratyne, Dimetapp, Benadryl
4 Days	Singulair
Foods	Ingestion of caffeine containing foods such as coffee, tea, cola and chocolate may affect bronchial hyper-responsiveness. These substances should be withheld on the day of the test.

Withhold Time	FeNO Breath Testing
8 Hours	On the day of the test, it is recommended to avoid any of the following 1 hour before the test: Eating Drinking NOTE: It is recommended to perform a FeNO test before spirometry.
12 Hours	It is recommended to avoid smoking for 12 hours before the test. It is recommended to avoid eating foods high in nitrates, this includes but is not limited to: Rocket Spinach Lettuce Radish Beetroot Chinese Cabbage Turnips Cabbage Green Beans Leek Spring Onion Cucumber Carrot Potato Garlic Sweet Pepper Green Pepper
24 Hours	It is recommended to avoid alcohol consumption for 24 hours before the test.
48 Hours
72 Hours
4 Days
Foods	Tips Do not inhale through the nose before exhaling through the mouthpieces. Be seated and relaxed when taking the test.

A Doctor will be present for the tests. Clinic staff will contact you with information about your tests.