Quality Assured Spirometry Referral Form

Quality Assured Spirometry Referral Form

Patient name
Date of Birth
NHS Number
Address
Telephone no(s)
Any special requirements
Referral to the Quality Assured Spirometry service / Please tick (☑
Is this to referral to confirm an existing diagnosis?
Is this to referral to confirm a new presentation?
Please check that the following contraindications have been excluded: / Please tick ☑
Haemoptysis of unknown origin (forced expiratory manoeuvre
may aggravate the underlying condition);
Pneumothorax;
Unstable cardiovascular status (forced expiratory manoeuvre may worsen
angina or cause changes in blood pressure) or ‘recent’ myocardial infarction
or pulmonary embolus;
Thoracic, abdominal or cerebral aneurysms (danger of rupture due to increased
thoracic pressure);
‘Recent’ eye surgery (e.g. cataract);
Presence of an acute illness or symptom that might interfere with test performance
(e.g. nausea, vomiting)
Recent thoracic or abdominal surgery
Chest infection or pneumonia
Referrer details
Name
Designation
GP Practice
Telephone no(s)
Email address
Date of referral

Please note advice from ‘A guide to Performing Quality Assured Diagnostic Spirometry’ *

Step 2: Pre-test advice to patients will depend on purpose of the spirometry: Investigative to establish diagnosis
Spirometry tests required: / ·  Base-line test
·  If obstructive base-line picture proceed to post-bronchodilator test (see below for standard)
Before the test STOP: / ·  Short acting bronchodilators for 4 hours
·  Long acting beta 2 agonist bronchodilators for 8 hours
·  Long acting anticholinergic bronchodilators for 36 hours
Before the test CONTINUE / ·  Inhaled and oral steroids
Ask the patient to avoid: / ·  Smoking for at least 24 hours before the test
·  Eating a large meal before the test
·  Vigorous exercise before the test
·  Wearing tight clothing
Ask the patient to bring existing inhalers to the appointment
Check if any contra-indications and ensure patient has a prescription for bronchodilator and volumatic
Please specify any allergies:

How would you like results communicated to you?

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