Northern
Respiratory

2 / 23 Philip Highway
Elizabeth  SA  5112
Ph: 8287 2040    Fx: 8255 5370
www.northernrespiratory.com.au
nrfureception@respiratorysa.com.au
Patient information
Name: 
Date of Birth: 			      Telephone:
Address:					

Referring Doctor Information
Name:
Address:
Fax:					       Telephone:

Tests Required:

☐ Spirometry (Flow Volume Curves)
       (Pre and Post Bronchodilator)
☐ Diffusing Capacity/Gas Transfer Factor 
      with Hb correction
☐ Static Lung Volumes
☐ Arterial Blood Gases 
    (via Clinpath) Request Form Required
☐ Mannitol Challenge Test
☐ Hypertonic Saline Challenge Test
☐ 6 Minute Walk Test
☐ Rhinomanometry

Clinical Indications – please include communicable diseases and Allergies

Doctor’s Signature:                                               Date:

Appointment

Date:                                             Time:

Patient Pre-Test Instructions
•	Please DO NOT SMOKE for 4 hrs 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 Northern Respiratory. 
•	Please call us if you have any concerns or queries
Test	Medication	Do Not Use For:	
Spirometry,
Diffusing Capacity
& Lung Volumes
(General lung function)	Ventolin, Bricanyl, Airomir, Asmol, Atrovent, APO

Serevent,  Seretide,  Oxis, Symbicort, B Nuelin SR , Bretaris, Brimica, Flutiform, 

Spiriva, Spiolto, OnBrez, SeeBri, UltiBro, Anoro, Breo, Incruse, Alvesco, Intal	6 hours

12 hours

24 hours	
Mannitol Challenge & Hypertonic Saline Challenge	Inhalers - time are the same as above,  
PLUS: do not take - All anti-histamines (eg. Telfast, Zyrtec, Claratyne, Polaramine, Phenergen etc)	48 hours	
6 Minute Walk	Please use all medications as usual INCLUDING INHALERS
Do not wear nail polish	-	
Rhinomanometry	Withhold all nasal decongestant sprays (eg. Spray-Tish, Otrivin, Sudafed, Vicks Sinex, Dimetapp etc)	8 hours