Patient Details:	
Surname:	First Name:	
DOB:  	Mobile:	
Address:	
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	

Referring Doctor Details:	
Doctors Name:		
Address:		
Signature:	Provider No:	
Date of Referral:	Fax No:	
Copy of Report to:	

Bronchial Provocation Testing	FeNO Breath Testing	
Withhold Time	Mannitol, Hypertonic Saline, Histamine	FeNO Breath Testing	
8 Hours	Ventolin, Asmol, Bricanyl, Intal, Tilade	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	Alvesco, Atrovent, Flixotide, Pulmicort, Qvar	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	Foradile, Nuelin, Oxis, Seretide, Serevent, Symbicort, Theodur	It is recommended to avoid alcohol consumption for 24 hours before the test.	
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.	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.