Lung Testing Form Data
Please follow these instructions in preperation for your test.
- Take any blood pressure medicines, insulin, antidepressants, cholesterol medicine and non-breathing related medicines if this is something you normally do.
- If you take pills or inhaled steroids (QVAR, Pulmicort, Flovent, Asmanex, Arnuity) you may continue to take then as usual.
24 hours before test: Stop all long acting bronchodilators
- Serevent
- Advair
- Foradil
- Spiriva
- Symbicort
- Brovana
- Incruse
- Breo
- Anoro
- Bevespi
- Stiolto Respimat
- Dulera
- Tudorza
- Oral Theophylline
6 hours before test: Stop all inhaled and tablet form short acting bronchodilators
- Primatene Tablets
- Albuterol Tablet
- Brethine Tablet
- Xopenex
- Atrovent
- Combivent
- Duoneb
- Albuterol (ProAir, Proventil, Ventolin)
- Maxair
Activities that should be avoided prior to testing
- Stop smoking at least 4 hour before test.
- No alcohol within 4 hours of testing
- No vigorous excercise within 30 minutes of testing
- Do not wear tight clothing that makes it difficult for you to take a deep breath
- Eating or Drinking within 2 hours of testing (a few sips of water are fine)
- No caffeine within 4 hours of testing
- No lipstick
Please bring in your authorization paperwork and/or RX from your doctor. It should have a written order for testing and suspected diabnosis. You must have this if your doctor gave it to you or we cannot administer the test. Please arrive early with paperwork completely filled out.
YOU WILL NOT BE SEEING DR. HENNINGER DURING THIS TESTING SESSION.
PFT Questionaire
FULL NAME : 3
Date : 2021-05-06
Referring Physician :
Sex : M
Date of Birth : 2021-04-27
Height :
Weight :
Race : Refuse to Answer
Ethnicity : Refuse to Answer
Preferred Language :
Reason for Testing : Other
Is this Pre-Op?No
What surgery is planned?
Previous Pulmonary Test?No
When/Where?
Smoking History : Never
Ex-Smoker : Packs/Day
For : Years
and Quit in :
Current Smoker : packs/day
for : Years
Occupation :
Exposures at work or in daily living? Other
Other :
Recent Respiratory Illness within last 6 wks? : None
Do you currently Use?
Other Meds that can effect lung function :
PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU
Used a short acting or "rescue" inhaler within the last 6 hrs? | No |
---|---|
Used a long acting "maintainence" inhaler within the last 24 hrs? | No |
Used bronchodilators pills within the last 8 days? | No |
Smoked within last 6 hrs? | No |
Had any caffeine containing food/drink within last 6 hrs? | No |
YOUR CARDIO-PULMONARY & SLEEP HISTORY :
PLEASE LIST ANY & ALL ALLERGIES :
PLEASE LIST YOUR CURRENT MEDICATIONS :
FAMILY HISTORY :
Document Photos
Insurance Card Front
Old Form Data, Photo not available.
Insurance Card Back
Old Form Data, Photo not available.
Driving Licence
Old Form Data, Photo not available.
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