Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
UNIVERSITY MEDICAL ASSOCIATES P.S.C                                                                                       ...
Upcoming SlideShare
Loading in …5

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


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

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