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Providence Health Care Pulmonary Diagnostics Requisition
IMPORTANT: Please indicate site below
St. Paul’s Hospital
Mount Saint Joseph Hospital
3080 Prince Edward St, Vancouver, BC V5T 3N4 TO BOOK AN APPOINTMENT PLEASE FAX REQUISTION
Not all tests are available at both sites. SPH ONLY indicates testing is only available at St. Paul’s Hospital
APPOINTMENT DATE:
PRECAUTIONS:
ALLERGIES/INTOLERANCES: (include drugs, food, latex and contrast media):
REASON FOR TESTING:
FOR DIAGNOSIS: Withhold respiratory medications – See reverse MONITORING THERAPY: Continue respiratory medications SPH ONLY DROP IN spirometry (no appointment necessary) Mon to Fri 1:00 pm to 3:30 pm *Requisition Required*
No DROP IN at MSJ – please book an appointment
Spirometry (FVC, FEV1, Flow volume loop) SPECIALIZED TESTING
Complete Pulmonary Function Test (includes pre/post flow volume loop, DLCO, lung volumes) Bronchial Challenge Test – A RECENT PRE AND POST SPIROMETRY TEST IS REQUIRED PRIOR TO BOOKING SPH ONLY Ventilatory Muscle Strength
GAS EXCHANGE/OXYGENATION
SPH ONLY Shunt calculation
EXERCISE TESTING (SPECIALISTS ONLY SECTION)
SPH ONLY STANDARD STAGE I Cardiopulmonary Exercise Test (MVO2) *Fax requisition to Cardiology: 604-806-9053
Does the patient have an Internal Cardiac Defibrillator?
YES
NO (Mandatory information required before test can be booked)
If Yes, please indicate the location where the ICD follow-up takes place:
SPH ONLY Exercise Induced Asthma Test (Eucapnic Voluntary Hyperventilation) *Fax requisition to Cardiology: 604-806-9053
SPH ONLY RESPIRATORY EDUCATION CENTRE (Referral includes pre/post spirometry on initial visit)
Referrals without a Clinical Diagnosis and Signature will not be processed
The back of this requisition contains important information for your patient
*EPHCRE001* Form No. PHC-RE001 (R. Apr 18-12) St. Paul’s Hospital
Mount Saint Joseph Hospital
For all tests at St. Paul’s Hospital and Mount Saint Joseph Hospital:
• Wear comfortable clothing for testing y Do not consume alcohol within 4 hours of testing • Do not eat a large meal within 2 hours of testing PULMONARY FUNCTION TESTS
Some medications will interfere with pulmonary function testing and should not be taken prior to your test, if
possible. However, if you do not think that you can go without, or you develop significant respiratory symptoms,
then continue your usual routine and inform the therapist that you have taken your medications before starting
your test.
DO NOT TAKE THE FOLLOWING MEDICATIONS:
Short-acting bronchodilators for at least 8 hours before your test
Example: AIROMIR (salbutamol), ATROVENT (ipratropium), BRICANYL (turbutaline),
Long-acting bronchodilators for at least 24 hours before your test
Example: ADVAIR (salmeterol-fluticasone), OXEZE (formoterol), SEREVENT (salmeterol),
(formoterol-budesonide), ZENHALE (formoterol-mometasone) • Long-acting anticholinergics for at least 24 hours before your test
Example: SPIRIVA (tiotropium)
CONTINUE TO TAKE THE FOLLOWING MEDICATIONS:
Anti-inflammatory (steroid containing) medications.
Example: ALVESCO (ciclesonide), FLOVENT (fluticasone), PULMICORT (budesonide),
• This does NOT include combination medications such as ADVAIR (salmeterol-fluticasone) and

METHACHOLINE CHALLENGE / BRONCHIAL CHALLENGE TESTS
On the day of your methacholine challenge test please avoid caffeine products such as coffee, tea, cola, or
chocolate
. Some medications will interfere with the testing and should be withheld prior to your test if possible.
DO NOT TAKE THE FOLLOWING MEDICATIONS:
Short-acting bronchodilators for at least 8 hours before your test
Example: AIROMIR (salbutamol), BRICANYL (terbutaline), VENTOLIN (salbutamol)
Medium-acting bronchodilators for at least 24 hours before your test
Example: ATROVENT (ipratropium)
Long-acting bronchodilators for at least 48 hours before your test
Example: ADVAIR (salmeterol-fluticasone), OXEZE (formoterol), SEREVENT (salmeterol),
(formoterol-budesonide), ZENHALE (formoterol-mometasone) • Leukotriene receptor antagonists for at least 24 hours before your test
Example: ACCOLATE (zafirlukast) and SINGULAIR (montelukast)
Long-acting anticholinergics for at least 7 days before your test
Example: SPIRIVA (tiotropium)
Antihistamines for at least 3 days before your test
Example: ALLEGRA (fexofenadine), AERIUS (desloratadine), CLARITIN (loratadine), REACTINE (cetirizine),
BENADRYL (diphenhydramine), CHLOR-TRIPOLON (chlorpheniramine) CONTINUE TO TAKE THE FOLLOWING MEDICATIONS:
Anti-inflammatory (steroid containing) medications
Example: ALVESCO (ciclesonide), FLOVENT (fluticasone), PULMICORT (budesonide),
• This does NOT include combination medications such as ADVAIR (salmeterol-fluticasone) and
AFTER YOUR TEST you may restart all your medications in the usual manner.

Source: http://medstaff.providencehealthcare.org/media/PHC-RE001%20Pulmonary%20Function%20Lab%20Requisition%20(R.%20Apr%2018-12)BC.pdf

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