2/23 Philip Highway (cnr Short Road)
Elizabeth 5112
Phone 8287 2040
Fax: 8255 5370
Email: reception@nrfu.com.au	
Website: www.nrfu.com.au

75 Fullarton Road
Kent Town 5067
Phone: 8364 4422
Fax: 8332 2236
Email: reception@respiratorysa.com.au
Website: www.respiratorysa.com.au

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

Clinic:                                          Fax / Email:		                        Telephone:

Tests Required:

☐ Spirometry (pre & post bronchodilator)
☐ Diffusing Capacity / Gas Transfer Factor 
    (inc. Hb correction)
☐ Static Lung Volumes
☐ Arterial Blood Gases (via Clinpath form required)
☐ Mannitol Challenge test
☐ Hypertonic Saline Challenge test

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.

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

6-Minute Walk Test: 
(Assess for supplemental oxygen – resp. physician to approve)
Gauge’s exercise-induced oxygen desaturation in patients with chronic disorders.  No treadmill used.

MIPs & MEPs:
Assesses the strength of respiratory muscles (diaphragm & abdominal and intercostal muscles).  Weakness common in neuromuscular conditions, COPD, heart disease.

☐ FeNO / Spirometry (Fractional Exhaled Nitric Oxide)
☐ Rhinomanometry
☐ 6 Minute Walk Test (Assess for supplemental oxygen – resp. physician to approve)
☐ High Altitude Simulation Test (Resp SA only)
☐ MIPs & MEPs (Resp SA only)
☐ Sleep Study (with or without consultation)

	

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 – if you cannot see your medications, please contact our clinic on the numbers listed below or visit our websites www.nrfu.com.au or www.respiratorysa.com.au for the most up to date list
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 
(General lung function)

FeNO / Spirometry test
(No food 1 hour prior).	Ventolin, Bricanyl, Airomir, Asmol, Zempreon

Atrovent (Ipratropium)

Seretide, Symbicort, Flutiform, Duoresp Spiromax, Serevent, Oxis, Fluticasone + Salmeterol Cipla, Nuelin SR, Fostair 

Spiriva, Spiolto, Onbrez, Seebri, Ultibro, Bretaris, Brimica, Anoro, Breo, Incruse, Trelegy, Trimbow, Bratlus, Enerzair, Atectura	8 hours

12 hours

24 hours

36 hours

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

Qvar, Pulmicort, Flixotide, Fluticasone Cipla, Atrovent – (Ipratropium)

Seretide, Symbicort, Flutiform, Duoresp Spiromax, Serevent, Oxis, Fluticasone + Salmeterol Cipla, Nuelin SR, Fostair

Spiriva, Spiolto, Onbrez, Seebri, Ultibro, Bretaris, Brimica, Anoro, Breo, Incruse, Trelegy, Trimbow, Bratlus, Enerzair, Atectura, Alvesco, Arnuity & ALL ANTI-HISTAMINES (Telfast, Zyrtec, Claratyne, Polaramine, Phenergen etc)

Singulair Tablets / Montelukast Tablets	8 hours

12 hours

36 hours

72 hours

4 Days	
6 Minute Walk &
High Altitude Simul.	Please use all medications as usual INCLUDING INHALERS
Do not wear nail polish	-	

Rhinomanometry	
Nasal decongestant sprays (e.g. Demazin, Dimetapp, Otrivin, Spray-Tish, Vicks Sinex)	
12 hours