P L E A S E S E E R E V E R S E F O R P A T I E N T I N S T R U C T I O N S A N D B O O K I N G D E T A I L S

R e s p i r a t o r y T e s t i n g S e r v i c e s

Dr Peter Bremner MD MBChB FRACPDr Quentin Summers DM MBBS FRACP

All AppointmentsTelephone: (08) 9381 3024

Fax: (08) 9381 3899Email: reception@lungs.com.au

P A T I E N T D E T A I L S

Surname

First Name Date of Birth / /

C L I N I C A L H I S T O R Y

Smoker Current c

Ex c

Never c

I N V E S T I G A T I O N S

c 1. FULL PULMONARY FUNCTION

c 2. SPIROMETRY c

c 3. BRONCHIAL PROVOCATION Histamine c Mannitol c URGENT

c 4. OXYGEN ASSESSMENT Exercise Oximetry c REPORT

c 5. SKIN PRICK TESTS REQUIRED

c 6. RESPIRATORY MUSCLE STRENGTH

c 7. ALTITUDE SIMULATION

c 8. CLINICAL CONSULTATION P. Bremner c Q. Summers c First Available c

R E F E R R I N G D O C T O R

Name Copy to:

Address

Signature Date

MidlandMurdoch (St John of God Medical Clinic)Subiaco (St John of God Medical Clinic)

For All Appointments - Tel: (08) 9381 3024 Fax: (08) 9381 3899 Email: lab@lungs.com.au

Lung Function ServicesRespiratory Testing

Dr Peter Bremner Dr Quentin Summers

F o r a l l a p p o i n t m e n t s p l e a s e t e l e p h o n e : ( 0 8 ) 9 3 81 3 0 2 4

A P P O I N T M E N T D E T A I L S

Date

Time

Location

Amount Payable on the Day $

Methods of Payment Available: Cash, Cheque, Eftpos or Credit Card

L O C A T I O N S

Subiaco Murdoch Midland

CAMBRIDGE ST

ST JOHN OF GOD HOSPITAL

CLINIC

McC

OU

RT S

T

MU

RDO

CH D

R

SOUTH ST

FREE

WAYHOSPITAL

WEXFORDCLINIC

THE CRESCENT

DOCTOR’S ROOMS

KEAN

E ST

GT EASTERN HWY

I M P O R T A N T P A T I E N T I N S T R U C T I O N S

FULL PULMONARY FUNCTION TEST - SPIROMETRY - BRONCHIAL PROVOCATION• On the day of the test: Do not smoke• 6 hours before the test: Do not take Ventolin, Bricanyl, Atrovent, Airomir, Asmol• 12 hours before the test: Do not take Serevent, Oxis, Symbicort, Seretide, Singulair, Accolate,

Flutiform, Foradile• 24 hours before the test: Do not take Spiriva, Onbrez, Seebri• Continue all other medications

BRONCHIAL PROVOCATION (IN ADDITION TO THE ABOVE INSTRUCTIONS)• On the day of the test: Do not take Intal Forte, Tilade or Theophylline• 3 days before the test: Do not take antihistamine medication, some cough mixtures may contain

antihistamine (please check with your pharmacist)• Continue all other medications

SKIN PRICK TEST• 3 days before the test: Do not take antihistamine medication, some cough mixtures may contain

antihistamine (please check with your pharmacist)• Continue all other medications

Please contact our rooms on 9381 3024 for advice as your test may need to be rescheduled; if you have taken, or need to take, any of the above medications within these time restrictions; if you are unsure whether to take a medication; if you are experiencing cold and flu or respiratory infection symptoms and/or taking prescription medication (eg. antibiotics) or over the counter medication (expectorants, decongestants). Vigorous exercise should not be performed on the day of the test.

Suite 323, Level 325 McCourt Street

St John of Gold Medical Clinic

Suite 20, Level 13 Barry Marshall ParadeWexford Medical Centre

23 The CrescentMidland Medical Specialist Centre