Please complete the form below or alternatively, download the PDF version and either email us at lungfunction@practicemail.com.au or fax the completed form to (07) 3350 5100. Lung Function Referral Form Patient Name:* Home Phone:Date of Birth:* DD MM YYYY Mobile:Email Address Street Address City ZIP / Postal Code Test/Tests Required Spirometry & Flow Volume Loops Pre & Post Bronchodilator Bedside Spirometry/Flow Volume Loops Positional Spirometry DLCO Gas Transfer Lung Volumes - Body Plethysmography Bronchial Provocation - Mannitol Challenge Smoking historyCurrent smokerFormer smokerNon smokerSmoking pack years(20 cigarettes/day on average=1 pack year)Most recent HbClinical Details:Referring Doctor Details (including provider number)Referring Doctor's fax/email for report:Date Date Format: DD slash MM slash YYYY If possible, please refrain from using inhalers, smoking or vigorous exercise 24 hrs prior to testing. Referral form format:PDF
