Referral to Lung Function & Sleep Department
Office Use only:
Date Rec’d:
Approved by:
Tel: 0121 371 3870
Fax: 0121 460 5822
Patient
Referring Clinician
Surname
Name
First Name
Practice Address /Telephone/ Fax
DOB
Address
Hospital No
NHS No
Practice No
Clinical Details:
Symptoms
Reason for Referral
 Dyspnoea
 Cough
 Sputum
 Wheeze
 Chest Pain
 Oedema
 Cyanosis
Other:
Last results from primary care
(if done)
FEV1
…………….
FVC
……………
MRC Score ……….
O2 Sats …………..
Diagnostic
 ?COPD (tested pre & post bronchodilator)
 ?Asthma
 ?Restrictive
 ? OSA
Monitoring
 Known COPD (tested post bronchodilator)
 Known Asthma
 Known restrictive disease
Other:
Tests Requested:
Routine Diagnosis
 Spirometry
(Initial Diagnosis)
Special Investigations
Assess for Long Term O2 Therapy
(SpO2<94%)
 Reversibility to Bronchodilators
Assess for Ambulatory O2 Therapy
(Routinely in initial diagnosis of COPD but not (Only in those already on LTOT)
necessary if diagnosis and degree of reversibility
already certain)
Assessment for Fitness to Fly
 Capillary/ Arterial Blood Gases
Assessment
for
long
term
nebulised
bronchodilators – Prescription must be attached
for referral to be processed (2/52 nebulised bd)
(In those with confirmed COPD routinely
requiring high doses of bronchodilators)
Sleep Studies
Onward Referral:
If a significant respiratory abnormality is discovered the lung function unit will proceed with testing in
accordance with UHBT policy and refer to a secondary care Respiratory Physician if necessary.
Past Medical History
Current Medication
 Short acting BD’s
 Long acting BD’s
 Inhaled Steroids
 Oral Steroids
 Beta blockers
 Oxygen
Other:
Any additional information:
Exclusion Criteria






Recent Eye Surgery
Recent Abdominal/Chest Surgery
Recent MI
Pneumothorax
Haemoptysis
Current Chest infection
Infection Status – if incomplete referral will be
rejected
MRSA
YES / NO
HEPATITIS B
YES / NO
HEPATITIS C
YES / NO
TB
YES / NO
Other Infection? (Please state)
Name of person completing form:
Position:
Signed:
Lung Function & Sleep Department
Level 0, Main Out-Patients Department
New Queen Elizabeth Hospital, B15 2WB
Date