Pulmonary Physiology Order Form

* Indicates Required Field

 

Patient Information

Example: 555-123-1234
Example: 555-123-1234
mm/dd/yyyy

Physician Information

Example: 555-123-1234

Pulmonary Function Test

Consists of Pre & Post Spirometry, lung volume, airways resistance & DLCO.
DLCO will only be done if age > 18 years.

Consists of Pre PV, Pre & Post lung volumes, Spirometry unless otherwise noted.
Does not include DLCO.

Consists of Pre & Post unless otherwise noted.

PI/PE MAX
DLCO
Spirometry
Consists of Pre only unless otherwise noted.
Helium Dilution
Consists of Pre only unless otherwise noted.

Gas Exchange

Arterial Blood Gas
Walking Pulse Oximetry
Pulse Oximetry (Single Evaluation)
Shunt Study
Hypercapnic Response
Hypoxic Response

Laryngoscopy

Laryngoscopy

Pulmonary Exercise

Patient must be evaluated prior to testing by ordering physician
Exercise Tolerance (+)
Consists of VO2, VCO2, VD/VT & VE.
Will be done Max only with an A-line unless otherwise noted.



EIB - Exercise Induced Bronchoconstriction (+)

Formal Exercise for Desaturation (+)
Consists of Pulse oximetry on Treadmill


Bronchial Provocation

Methacholine Challenge (+)
Consists of Spirometry only, unless otherwise noted.
Irritant Challenge (+)


Allergen Challenge (+)
Preferred Performing MD for Laryngoscopy
Special Instructions
(+) Albuterol 360mcg MDI or 2.5mg Neb unless otherwise ordered
or
Xopenex 1.25mg or Xopenex 0.63mg Neb unless otherwise ordered
Modifications to test *

E-Signature


1-800-222-5864
Refer a Patient

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