Spirometry Questionnaire

Please submit this form as soon as possible before your spirometry appointment.

If you answer Yes to any of the questions, your spirometry appointment may need to be rescheduled and you will be contacted by the Practice.

Spirometry Pre-Appointment Questionnaire

Your details

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Possible contraindications to spirometry

Please let us know if you have or had any of the following:
Coughing up blood
Current chest pain
Nausea, vomiting or diarrhoea in the last 48 hrs
Current/recent chest infection within last 6 weeks
Active TB
Bullous emphysema (a chronic lung condition)
Uncontrolled high blood pressure (hypertension)
Heart attack (myocardial infarction) in the last 7 days
Unstable or uncontrolled angina
Collapsed lung (pneumothorax) in the last 3 weeks
Pulmonary embolus (blood clot in the lung)
Chest or abdominal (tummy) surgery in the last 4 weeks
Previous stroke
Brain surgery in the last 3-6 weeks
Chest, abdominal (tummy) or brain aneurysms
Vascular surgery in the last 4-6 weeks
Eye surgery within the last 6 weeks
Detached retina in last 8 weeks
Middle ear infection which has been treated in the last 2 weeks
Ear perforation in the last 4 weeks