Patient Information Payment Details Hospital number: Payment Method: Insurance Embassy Self-Funding Payment Provider: Title: Surname: Forename(s): Requested Respiratory Procedure Address: Spirometry Gas Transfer Postcode: Static Lung Volumes (Plethysmography) Date of birth: / / Bronchodilator response: Ventolin Atrovent Gender: Male Female End Capillary Blood Gases Contact Tel: Cardiopulmonary Exercise Test (Please complete contraindications on reverse side of form) Mobile No.: If other tests required please specify: Interpreter required: Yes No Language: Appointment Booked: / / Time: Additional Information Please complete if Spirometry requested Patient transport: Walking Wheelchair Bed Relative Contraindications: Infection Risk: Yes No Details: Haemoptysis of unknown origin: Yes No Recent pneumothorax: Yes No Allergies: Recent myocardial infarction: Yes No Pregnant: Yes No Pulmonary embolism: Yes No Oxygen: Yes No Thoracic, abdominal or cerebral aneurysms: Yes No Asthma: Yes No Recent eye surgery; raised intra-ocular pressure: Yes No Beta Blockers: Yes No Recent thoracic or abdominal surgical procedures: Yes No Recent syncope: Yes No Diabetic: Yes No Controlled by: Diet Tablets Insulin Cervical neck problems: Yes No Recent surgery: Yes No Any other physical problem: Yes No Please specify surgery: Clinical Indication for Examination Please summarise relevant history, clinical findings and previous test results. Please indicate the question that the examination aims to answer: N.B. This form is a legal document Referrer’s Declaration – Referrer name: The correct patient details have been provided. I have discussed the examination, GMC: including any intervention with the patient / guardian. I have taken into account the possibility of pregnancy. I have given sufficient clinical information for the request to be Address: justified according to IR(ME)R 2000 (if applicable). I will ensure that the examination results are recorded in the patient’s notes. Postcode: Tel: Signature: Email: Date: / /
Patient Information Hospital number: Title: Surname: Forename(s): Address: Postcode: Date of birth: / / Gender: Male Female Contact Tel: Mobile No.: Interpreter required: Yes No Language: Appointment Booked: / / Time: Payment Details Payment Method: Insurance Embassy Self-Funding Payment Provider: Requested Respiratory Procedure Spirometry Gas Transfer Static Lung Volumes (Plethysmography) Bronchodilator response: Ventolin Atrovent End Capillary Blood Gases Cardiopulmonary Exercise Test (Please complete contraindications on reverse side of form) If other tests required please specify: Additional Information Patient transport: Walking Wheelchair Bed Infection Risk: Yes No Details: Allergies: Pregnant: Yes No Oxygen: Yes No Asthma: Yes No Beta Blockers: Yes No Recent syncope: Yes No Diabetic: Yes No Controlled by: Diet Tablets Insulin Recent surgery: Yes No Please specify surgery: Please complete if Spirometry requested Relative Contraindications: Haemoptysis of unknown origin: Yes No Recent pneumothorax: Yes No Recent myocardial infarction: Yes No Pulmonary embolism: Yes No Thoracic, abdominal or cerebral aneurysms: Yes No Recent eye surgery; raised intra-ocular pressure: Yes No Recent thoracic or abdominal surgical procedures: Yes No Cervical neck problems: Yes No Any other physical problem: Yes No Clinical Indication for Examination Please summarise relevant history, clinical findings and previous test results. Please indicate the question that the examination aims to answer: Referrer name: GMC: Address: Postcode: Tel: Email: N.B. This form is a legal document – Referrer’s Declaration The correct patient details have been provided. I have discussed the examination, including any intervention with the patient / guardian. I have taken into account the possibility of pregnancy. I have given sufficient clinical information for the request to be justified according to IR(ME)R 2000 (if applicable). I will ensure that the examination results are recorded in the patient’s notes. Signature: Date: / /
RBHH-Specialist-Care-Lung-Function-Referral-Form-April-2017.docx