MBChB (CUHK), MRCP (UK)
FRACP (Respiratory Medicine)

Patient Details:
Name:  	

Date of birth:	/	/ 	

Address:  	

Phone:	 	 Clinical history:

E-mail:  	

 	_

Consultation Requested:
•	Respiratory
•	Sleep

Investigation Requested:
•	Full lung function tests (spirometry- before and after bronchodilator, lung volumes, gas transfer)
•	Spirometry (Before and after bronchodilator)
•	Bronchial Provocation Test (Mannitol Challenge Test)
•	FENO (Fractional Exhaled Nitric Oxide – non-invasive measurement of
airway inflammation)
•	Respiratory Muscle Strength (MIPS/MEPS & Postural Spirometry)
•	Level 2 home sleep study

Referring Doctor Details:
Name:  	

Provider Number:  	

Address:  	
Phone:		Fax:  	
Copy of report to   	

Signature:		Date of Referral:  	

Tenancy 211, 1808 Logan Road, Upper Mt Gravatt 4122
Ph: (07) 3705 0808	Fax: (07) 3319 4627
E-mail: reception@southcityrespiratory.com.au