ATS Pulmonary Function Laboratory Manual

ATS Pulmonary Function Laboratory Management & Procedure Manual | 3rd Edition

Appendix 3.3  Example of a Questionnaire for PF Testing Name: _____________________________________________________________________________

Sex: ____________ Age today: _______________ Date of Birth: ______________________________

Home Phone: ____________________________ Business Phone: _____________________________

Ordering Physician: __________________________________________________________________

Your Occupation: ____________________________________________________________________

[ ] Yes [ ] Yes

[ ] No [ ] No

Have you been tested in this laboratory before: .1 If yes, was it under a di‚erent name than shown above?

If yes, what name? _______________________________________________ If yes, when approximately? ________________________________________

[ ] Yes [ ] Yes

[ ] No [ ] No

Have you ever smoked cigarettes? .2 If yes, do you still smoke now? If you quit, how long ago? If you smoke(d), how many years did you/have you smoked? How many packs per day (average)? 3. bronchitis or a chest cold in the last 6 weeks? 4. Have you had more than two cups of ca‚einated co‚ee in the last 2 hours? Have you had a respiratory infection, such as a –u,

[ ] Yes

[ ] No

[ ] Yes

[ ] No

5. Have you used an inhaled bronchodilator (e.g., albuterol, Atrovent, Combivent, Proventil, salmeterol, Advair, and Ventolin) in the last 8 hours?

[ ] Yes

[ ] No

6. Have you taken any bronchodilator pills (e.g., montelukast, theophylline) in the last 8 hours?

[ ] Yes

[ ] No

7. Have you taken any other medications for your lungs, heart, or blood pressure (e.g., beta-blockers)?

[ ] Yes

[ ] No

[ ] Yes

[ ] No

8. Are you currently receiving chemotherapy for the treatment of cancer

30