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UNIVERSITY MEDICAL ASSOCIATES P.S.C                                                                                       ...
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Pft order form, revised 2010 09-23, version 8

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Pft order form, revised 2010 09-23, version 8

  1. 1. UNIVERSITY MEDICAL ASSOCIATES P.S.C DIVISION OF PULMONARY, CRITICAL CARE & SLEEP DISORDERS MEDICINE 401 EAST CHESTNUT ST. SUITE 310 LOUISVILLE, KY 40202Located at the UofL Healthcare Outpatient Center PHONE (502) 855-7856 F AX ( 502 ) 8 13- 63 89 * PLEASE ATTACH RECENT PATIENT DEMOGRAPHICS & INSURANCE INFORMATION TO EXPEDITE SCHEDULING*Patient Name: ____ D.O.B: ___Home Phone: __ Work Phone: ___ Cell Phone: ___DIAGNOSES:_____________________________________________________________________________________ Please provide the diagnoses (signs, symptoms, reason for referral) including codes, and other pertinent clinical information.WHERE WOULD YOU LIKE THE RESULTS TO BE SENT UPON COMPLETION? *Default is sent to ordering physician* Fax: ___ E-Mail:  Mailing Address:  Today ( if schedule permits )  To be scheduled _______ _______ PUMONARY FUNCTION TESTING FUNCTIONAL CAPACITY Complete PFTs + Pre & Post Bronchodilator Testing  6 Minute Walk Test (following ATS standards) CPP SIX (spirometry, lung volumes and DLCO (albuterol 2.5 mg nebulizer)  Multiple Pulse Oximetry Test MPO Complete PFTs (spirometry, lung volumes and DLCO) CDL  Multiple Pulse Oximetry Test with POO Spirometry (includes flow-volume loop and MVV) FVL Oxygen Titration Spirometry + Pre & Post Bronchodilator Testing SPP  Cardiopulmonary Exercise Testing EXT (albuterol 2.5 mg nebulizer) Lung Volumes (TLC, FRC, RV, VC, etc.) TLC Carbon Monoxide Diffusing Capacity (DLCO) DLC Maximum Inspiratory and Expiratory Pressures (MIP / MEP) MIP BRONCHIAL HYGIENE & MAINTENANCE ADDITIONAL TESTING Small Volume Nebulizer Treatment  Methacholine Challenge Testing (asthma SVN MCH  Albuterol 2.5 mg evaluation)  Levalbuterol (Circle: 1.25 mg, 0.63 mg)  Arterial Blood Gas ABG  Ipratropium Bromide (Atrovent) 0.5 mg CIRCLE: room air or supp O2 ___________l/min) Induced Sputum with hypertonic saline SNA  Today  Scheduled Nasal Tracheal Suctioning NSX  Exercise-induced Bronchospasm EIB One on One Patient Education PED  Over Night Oximetry Study ONO  Deep Breath & Cough  Exhaled Nitric Oxide  Purse Lip Breathing  Transcutaneous hemoglobin  MDI and Medication Instruction and Techniques measurement  Other:Comments: _______________________________________________________________________________ _____Name of Practice/Medical Facility: _____Referring Physician: Date: ______Ordering Physician: NPI #: Date: ______ Order Form rev 2009–09-17 ver 8

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