□   RESPIRATORY  SA			        	□   NORTHERN  RESPIRATORY
75 Fullarton Road	 - new address as at 2/1/2019		2/23 Philip Highway (cnr Short Road)
Kent Town 5067						Elizabeth  5112	
Phone: 8364 4422   Fax: 8332 2236				Phone: 8287 2040   Fax: 8255 5370
Email: reception@respiratorysa.com.au			Email: reception@nrfu.com.au 
Website: www.respiratorysa.com.au			Website: www.northernrespiratroy.com.au 

Patient Information
Name: 
Date of Birth: 					Telephone:
Address:
					
Referring Doctor Information
Name:
Address:
Fax:						Telephone:

Tests Required:

☐ Spirometry
☐ Diffusing Capacity / Gas Transfer Factor 
    (inc. Hb)
☐ Static Lung Volumes
☐ Mannitol Challenge
☐ Hypertonic Saline Challenge
☐ 6 Minute Walk Test (Assess for supplemental oxygen – resp. physician to approve)
☐ High Altitude Simulation Test (Resp SA only)
☐ Rhinomanometry
☐ Arterial Blood Gases   (Clinpath form required)

Suspecting asthma?
Spirometry and either Mannitol Challenge or Hypertonic Saline Challenge.
(Any smoking history? Also select Diffusing Capacity)

Suspecting COPD or restriction?
Spirometry, Diffusing Capacity and Static Lung Volumes.
(Diffusing capacity- assess O2 transfer from alveoli to capillaries. Lung Volumes – assess for hyperinflation, gas trapping, restriction.)

6-Minute Walk Test: 
Assesses exercise-induced oxygen desaturation in patients with chronic disorders. Titrate supplemental oxygen requirements. No treadmill used.

High Altitude Simulation Test:
For patients whose blood oxygen levels may decrease while flying.

		

Clinical Notes:

Doctor’s Signature:                                               Date:

Patient Pre-test Instructions
•	Please DO NOT SMOKE for 4 hours prior to testing.
•	Check the following table for respiratory medications not to be taken prior to test.
•	HOWEVER... If you become short of breath, wheezy or feel unwell, take your medication as prescribed and contact our clinic.  Please call us if you have any concerns or queries.
Test	Medication	Do Not Use For:	

Spirometry,
Diffusing Capacity
& Lung Volumes tests
(General lung function)	Ventolin, Bricanyl, Airomir, Asmol, Atrovent

Seretide, Symbicort, Bretaris, Brimica, Flutiform, Duoresp, Serevent, Oxis, Fluticasone + Salmeterol Cipla, Nuelin SR

Spiriva, Spiolto, Onbrez, Seebri, Ultibro, Anoro, Breo, Incruse, Trelegy, Intal	6 hours

12 hours

24 hours	

Mannitol Challenge & Hypertonic Saline
Challenge	Ventolin, Bricanyl, Airomir, Asmol

Qvar, Pulmicort, Flixotide, Fluticasone Cipla, Atrovent

Seretide, Symbicort, Bretaris, Brimica, Flutiform, Duoresp, Serevent, Oxis, Fluticasone + Salmeterol Cipla, Nuelin SR

Spiriva, Spiolto, Onbrez, Seebri, Ultibro, Anoro, Breo, Incruse, Trelegy, Intal
& ALL ANTI-HISTAMINES (Telfast, Zyrtec, Claratyne, Polaramine, Phenergen etc)
	8 hours

12 hours

24 hours

72 hours	
6 Minute Walk &
High Altitude Simul.	Please use all medications as usual INCLUDING INHALERS
Do not wear nail polish	-	
Rhinomanometry	Nasal decongestant sprays (eg. Demazin, Dimetapp, Otrivin, Spray-Tish, Vicks Sinex)	12 hours