Breathe Ease
Respiratory & Sleep Services
P: 07 4634 6933
F: 07 4634 6911
E: reception@trss.com.au

Referral Form
LUNG FUNCTION / CONSULTATION

Dr Gonesh Karmakar
Suite 109, 1808 Logan Road
Upper Mt Gravatt, QLD, 4122

Patient Details:	
Name: _______________________________________________________Date of Birth:_____ /____ /____
Address: ________________________________________________________________________________
Home phone:______________________________________Mobile:________________________________
Referred by:	
Name:__________________________________________________Provider No.:_____________________
Signature/stamp:									Date:

        

        

Services required:                                                          URGENT                 NON-URGENT	
CONSULTATION:   	 Yes              No								
        Full Lung Function (includes spirometry, lung volumes and gas transfer)	
        Spirometry (pre & post bronchodilator)                                                                              6 minute walk test
        FeNO – Fractional Exhaled Nitric Oxide                                                                                Air         O2
        Bronchial Provocation Test (Mannitol)                                                                                 Overnight Oximetry
        Respiratory Muscle Strength (MIPS & MEPS)                                                                      Sleep Apnoea
        Lying and Standing								
CLINICAL NOTES: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MEDICATIONS: __________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PATIENT INSTRUCTIONS
ALL TESTS
•	Do not smoke for at least 1 hour before the test 
•	Do not consume alcohol or caffeinated drinks 4 hours prior to testing 
•	Do not perform vigorous exercise for 1 hour before the test 
•	Do not east a large meal or have a big drink for 3 hours prior to testing 
•	Do not wear restrictive clothing 
SPIROMETRY
•	Do not take relievers such as Ventolin, Bricanyl, Atovent or Asmol on the day of testing, however take them if you feel like you need them
•	Do not take long acting relievers such as Oxis, Symbicort, or Serevent for 12 hours prior to testing 
TRANSFER FACTOR 
Avoid smoking for 24 hours prior to testing if possible. 
BRONCHIAL PROVOCATION TEST (MANNITOL CHALLENGE) 
You will be given some Mannitol (a sugary powder), to inhale. Between doses, you will perform breathing tests to assess your response to Mannitol. Before this test, please avoid the medications below for the specified period. However, if you feel that you need them, please do, but the testing will have to be rescheduled. 
Day of test 			Caffeine (coffee, energy drinks, Coca Cola, Pepsi, or chocolate) 
				Do not smoke or perform vigorous exercise 

8 hours before test		Ventolin, Bricanyl, Asmol, Airomir, Atrovent, Intal, Tilade
12 hours before test		Pulmicort, Flixotide, Alvesco, Qvar, Arnuity 
24 hours before test 		Nuelin (Theophylline)
48 hours before test 		Seretide, Symbicort, Serevent, Breo Ellipta, Oxis
72 hours before test		Spiriva, Seebri, Bretaris, Ultibro, Anoro ellipta, Brimica, Incruse Ellipta
				Antihistamines, such as: Zyrtec, Telfast, Claratyne, Polaramine, Phenergan
4 days before test 		Singulair