BRISBANE                      
Wesley Medical Centre
Suite 26, Level 2
40 Chasely Street 
Auchenflower Q 4066
Ph: (07) 3607 5190 Fax: (07) 3607 5196
North St Medical Centre            
St Andrews Hospital
457 Wickham Tce
Spring Hill Q 4000
Ph: (07) 3054 1228 Fax: (07) 3054 1229
Ramsay Specialist Centre          
Suite 322, Level 3 
121 Newdegate St 
Greenslopes Q 4120 
Tel: (07) 3074 0140 Fax: (07) 3074 0141
NORTHLAKES                  
9 McLennan Court 
North Lakes, Q 4509 
Tel: (07) 3607 5190 Fax: (07) 3607 5196
IPSWICH                        
Suite 3, Level 1
18 Limestone Street
Ipswich Q 4305
Ph: (07) 3050 7102 Fax: (07) 3050 7103
SPRINGFIELD CENTRAL        
Greater Springfield Specialist Suites Suite 503, Level 5 Cnr Health Care Dr & Wellness Way, 
Springfield Central Q 4300 
Tel: (07) 3180 8290 Fax: (07) 3180 8291
GOLD COAST                   
Pindara Private Hospital, Level 1
39 Allchurch Ave
Benowa Q 4217
Ph: (07) 5610 5812 Fax: (07) 2610 5813
SUNSHINE COAST              
Pulse Oceanside Medical 
Suite 402, Level 3 
11 Eccles Boulevard 
Birtinya Q 4575 
Tel: (07) 5353 5166 Fax: (07) 5353 5167
TOOWOOMBA                  
St Vincents Hospital
Entrance 3, Level 2, Scott Street
Toowoomba Q 4350
Ph: (07) 4646 4250 Fax: (07) 4646 4253
St Andrew's Hospital              
Building 4, Suite 31, Level 1 
280 North St 
Rockville Q 4350 
Tel: (07) 4592 8086 Fax: (07) 4592 8087
BUNDABERG                   
Mater Medical Suites
Suite 3, 313 Bourbong Street 
Bundaberg Q 4670
Ph: (07) 4304 8001 Fax: (07) 4304 8002
HERVEY BAY                   
St Stephens Private Hospital
1-11 Medical Place
Urraween Q 4655
Ph: (07) 4313 1160 Fax: (07) 4313 1161

MACKAY                    
Mackay Private Hospital
Suite 1, 57 Norris Road
North Mackay, Q 4740
Ph: (07) 4805 6441 Fax: (07) 4805 6440
ROCKHAMPTON            
Mater Misericordiae Hospital
Suite 1, Level 1
31 Ward St
Rockhampton Q 4700
Ph: (07) 4807 6512 Fax: (07) 4807 6513		
	
Respiratory Function
Request Form
www.qldrespiratory.com.au
Lung Function Test Bookings 
Tel: (07) 3607 5194
E: reception@qldrespiratory.com.au 

Patient Details:

Surname: ________________  First Name: ___________________   

DOB:      ___________

Address:  _______________________________________________

Home Ph:  ____________ Work: __________ Mobile: ___________ 

Clinical History / Details: __________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Investigations Required:

  Full lung function (Flow Volume Loops, lung volumes & gas transfer)
          - before & after bronchodilator
  Flow Volume Loops - before & after bronchodilator
  Cardiopulmonary Exercise Test (Wesley & Toowoomba)
   Bronchial provocation:
          Mannitol challenge	
  Hypertonic saline (Wesley)	

          Histamine Challenge (Wesley)	

  Allergen Skin Prick Test
  Hypoxic Altitude Simulation Test (Wesley, Bundaberg & Hervey Bay)
  Respiratory Muscle strength (MIPS/MEPS & postural FVL/SNIP) 
  Six Minute Walk Test -single trial without O2
  Six minute Walk Test -dual trial without & with O2 for MASS evaluation
  Overnight Oximetry
  Exhaled Nitric Oxide -FeNO (Pindara)
  
Referring Doctor Details:

Doctors Name:  _________________________________________

Address: _______________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Signature: ___________________      Provider No: ___________ 

Date of Referral: ____________ Fax No. for Report: ____________ 

Copy of Report to: ____________________________________________________

	

Medication - Withholding Times Prior to Test
Time	Full Lung Function or Flow Volume Loops	
8 Hours	Airomir, APO, Asmol, Bricanyl, Intal, Tilade, Ventolin	
12 Hours	Atrovent, Brimica, Flutiform, Pulmicort, Qvar, Seretide, Serevent, Symbicort	
24 Hours	Alvesco, Anoro, Breo, Foradile, Incruse, Nuelin, OnBrez, Seebri, Spiriva, Spiolto, Theodur	
3 Days	Bretaris, OnBrez, Seebri, Spiriva, UltiBro	
4 Days	Singulair	
	Bronchial Provocation and Cardiopulmonary Exercise Test	
8 Hours	Airomir, APO, Asmol, Bricanyl,  Intal, Tilade, Ventolin	
12 Hours	Atrovent, Brimica, Flutiform, Pulmicort, Qvar	
24 Hours	Alvesco, Anoro, Breo, Foradile, Incruse, Nuelin, Oxis, Serevent, Seretide, Spiolto, Symbicort, Theodur	
3 Days	Bretaris, OnBrez, Seebri, Spiriva,  UltiBro	
4 Days	Singulair	
	Anti-Histamines - For All Tests	
3 Days	Avil, Benadryl, Claratyne, Claramax, Periactin, Phenergen, Polaramine, Telfast , Zadine, Zyrtec	
	Non- medication - For All Tests	
	Ingestion of food containing caffeine should be withheld on the day of the test, as it can decrease bronchial hyper-responsiveness.	
	Smoking and vigorous exercise should not be undertaken on the day of the test.	

Cardiopulmonary Exercise Test
Day of test - avoid heavy meals, smoking and alcohol consumption. Wear comfortable shoes and clothing for riding a bike. On the day of the test report to Reception, Level 2, Suite 26 Wesley Medical Centre, Wesley Hospital or Respiratory Laboratory at St Vincent's Hospital (Toowoomba) at the appointed time. A doctor will be present for the testing.

Allergen Skin Prick Test
72 hours before test - do not take antihistamines e.g Claratyne, Avil, Zyrtec etc. Note: Mood stabilisers (e.g. Endep, Avanza) can cause a false negative test. Please inform staff when making your booking if you are taking prednisolone. 

Respiratory and Sleep Specialists
To book an appointment with a Respiratory Physician please call one of the following numbers. Locations can be found at our website www.qldrespiratory.com.au/our-physicians

Dr Farzad Bashirzadeh	(07) 3871 0033  	  Dr Maurice Heiner	(07) 3870 4468	
Dr Michael Bint	(07) 5332 5900   	  Dr Justin Hundloe	(07) 3870 4133	
Dr Ian Brown	(07) 3832 1717  	  Dr Charl Liebenberg	(07) 4153 9414	
Dr David Deller	(07) 5539 4674  	  Dr Lee Rafter	(07) 4688 5480	
Dr Robert Edwards	(07) 3870 4511  	  Dr Alex Ritchie	(07) 3832 7776	
Dr Iain Feather	(07) 5597 1622  	  Dr Chris Zappala	(07) 3371 0500