Contact us to book Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Do you have a referral? * Yes No Age * Date of Birth * Birth Gender Male Female Reason for requesting lung function * Do you smoke? * Current smoker Never smoker Ex smoker Do you take inhalers for your breathing? * Please state any inhalers or medications you take for your breathing Present symptoms Tick all that apply to you Cough Wheeze Sputum Shortness of breath Chest tightness Chest infection Chest pain Any other symptoms? Do you have any allergies? * Contraindications for lung function testing (please tick any that apply to you) * Coughing up of blood. Active untreated tuberculosis Brain, abdominal or chest aneurysms (bulging arteries) Collapsed Lung Unstable Angina Recent Heart Attack or Stroke Lung clots Surgery - brain, eyes, chest or abdomen chest infection in the last 6 weeks pregnant Acute illness (nausea, vomiting etc) in the last 48 hours? None of the above Clinical indications * New cough that does not go away after 3 weeks A change in your normal cough that has got worse Coughing up of blood in sputum (phlegm) Recurrent chest infections Persistent shortness of breath Loss of appetite or unexplained weightloss Fatigue - feeling tired or weak all the time Chest pain that worsens when breathing, coughing Hoarseness for more than 3 weeks. Swelling in the neck, arms or upper chest. None of the above Do you have any other medical conditions? Please tick any that apply Diabetes Heart issues High blood pressure Kidney issues Vascular disease Any other details we should know? * Preferred Location * Loughview Health Lurgan Friends Medical Service Lurgan Duality Health Omagh Duality Health Newry Duality Health Galgorm Thank you for contacting us! We will be in touch shortly to advise you on the next steps.
