WESLEY MEDICAL CENTRE
Level 2, Suite 26, 40 Chasely St
AUCHENFLOWER Q 4066
Tel: (07) 3607 5190 Fax: (07) 3607 5196

ST ANDREW’S PLACE
Ground Floor, 33 North St
SPRING HILL Q 4000
Tel: (07) 3054 1228 Fax: (07) 3054 1229

IPSWICH
Level 1, Suite 3, 18 Limestone St
IPSWICH Q 4305
Tel: (07) 3050 7102 Fax: (07) 3050 7103

GREATER SPRINGFIELD 
SPECIALIST SUITES
Level 5, Suite 503, Cnr Health Care Dr &
Wellness Way
SPRINGFIELD CENTRAL Q 4300 
Tel: (07) 3180 8290 Fax: (07) 3180 8291

Investigation Required:
o	Complex Lung Function (flow volume loops, lung volumes, gas transfer)
              ○ With bronchodilator testing    ○ No bronchodilator testing
o	Spirometry/flow volume loops - before & after bronchodilator
o	Cardiopulmonary Exercise Test (Wesley) 
o	Bronchial Provocation:
                ○ Mannitol    ○ Hypertonic Saline (Wesley)    ○ Histamine (Wesley)
o	Allergen Skin Prick Test (Wesley, Bundaberg, Hervey Bay & Ipswich)
o	Hypoxic Altitude Simulation Test (Wesley, Bundaberg & Hervey Bay)
o	Respiratory Muscle Strength (MIPS/MEPS & postural spirometry)
o	Postural Spirometry (seated & supine)
o	6 Minute Walk Test (single trial without O2)
o	6 Minute Walk Test (dual trial without and with O2 for MASS evaluation)
o	Overnight Oximetry
o	FeNO - Fractional Exhaled Nitric Oxide (with spirometry)

ST VINCENT’S HOSPITAL 
Entrance 3, Level 2, Scott St
TOOWOOMBA Q 4350
Tel: (07) 4646 4250 Fax: (07) 4646 4253

ST ANDREW'S HOSPITAL 
Building 4, Level 1, Suite 31
280 North St 
ROCKVILLE Q 4350
Tel: (07) 4592 8086 Fax: (07) 4592 8087

PINDARA PRIVATE HOSPITAL
Level 1, 39 Allchurch Ave
BENOWA Q 4217
Referring Doctor Details:
Doctors Name: ...............................................................................................
Address: ........................................................................................................
........................................................................................................................
Signature: .................................. Provider No: ..............................................
Date of Referral: ......./......./...........
Email/Fax Report.....................................................................................................
Copy of Report to: .............................................................................................

Referring Doctor Details:
Doctors Name: ...............................................................................................
Address: ........................................................................................................
........................................................................................................................
Signature: .................................. Provider No: ..............................................
Date of Referral: ......./......./...........
Email/Fax Report.....................................................................................................
Copy of Report to: .............................................................................................

Tel: (07) 5610 5812 Fax: (07) 5610 5813

GOLD COAST PRIVATE HOSPITAL
Level G, Suite 11, 14 Hill St         SOUTHPORT Q 4215 
Tel: (07) 5615 0005 Fax: (07) 5615 0006

ICON CANCER CENTRE
Level 1, 9 McLennan Court 
NORTH LAKES Q 4509
Tel: (07) 3607 5190 Fax: (07) 3607 5196

PULSE OCEANSIDE MEDICAL
Level 5, Suite 605
11 Eccles Boulevard 
BIRTINYA Q 4575
Tel: (07) 5353 5166 Fax: (07) 5353 5167

Referring Doctor Details:
Doctors Name: .........................................................................................
Address: ...................................................................................................
..................................................................................................................
Signature: ...................................... Provider No: .....................................
Date of Referral: ......./......./...........
Email/Fax: ................................................................................................
Copy of Report to: ....................................................................................

ST STEPHEN’S HOSPITAL
1-11 Medical Place
HERVEY BAY Q 4655
Tel: (07) 4313 1160 Fax: (07) 4313 1161

MATER MEDICAL SUITES
Suite 3, 313 Bourbong St
BUNDABERG Q 4670
Tel: (07) 4304 8001 Fax: (07) 4304 8002

MACKAY PRIVATE HOSPITAL
57 Norris Road
MACKAY Q 4740
Tel: (07) 4805 6441 Fax: (07) 4805 6440

MATER PRIVATE HOSPITAL

            QIP Accredited RSHQ Spirometry Provider

Suite 1, Level 1, 31 Ward St
ROCKHAMPTON Q 4700
Tel: (07) 4807 6512 Fax: (07) 4807 6513

   Respiratory Function Test Request Form

Test Bookings Tel: (07) 3607 5194

Patient Details:
Surname: ............................................... First Name:  .........................................
DOB: .........../.........../.............
Address: ..........................................................................................................
Home Ph: ............................ Work: ........................... Mobile: ..........................
Clinical History/Details: ….......................................................................................
.........................................................................................................................
.........................................................................................................................
.........................................................................................................................

E: reception@qldrespiratory.com.au       www.qldrespiratory.com.au

Queensland Respiratory Services offer a full range of lung function and allergy testing in an accredited laboratory backed by the largest private respiratory
physician group in the state

Test Preparation

 All Tests

                                                               Inhaler withholding times	
8 Hours	                                         Asmol®, Bricanyl®, Ventolin ®, Zempreon®	

Ingestion of food containing caffeine should be withheld on the day of the test, as it can decrease bronchial hyper-responsiveness. Smoking and vigorous exercise should not be undertaken on the day of the test.
     
Bronchial Provocation

Inhaler withholding times	
4 Hours	                                                            Intal®, Tilade®	
8 Hours	                                                Ventolin®, Asmol®, Bricanyl® 	
12 Hours	         Pulmicort®, Flixotide®, Fluticasone Cipla®, QVAR®, Alvesco®, Arnuity®, Atrovent®	
24 Hours	                  Foradile Theo-Dur®, Nuelin®  	
36 Hours	    Seretide®, Cipla®, Symbicort®, DuoResp®, Breo®, Flutiform ®, Serevent ®, Oxis®, Onbrez®	
3 Days	 Spiriva®, Bretaris®, Incruse®, Seebri®, Brimica®, Anoro®, Ultibro®, Spiolto®, Trelegy®, Trimbow®	
4 Days	                                  Singulair®	
                     Antihistamine withholding times	
3 Days	Avil®, Benadryl®, Claratyne®, Claramax®, Periactin®, Phenergan®, Polaramine®, Telfast®, Zyrtec®	

Cardiopulmonary Exercise Test
Day of test - avoid heavy meals, smoking and alcohol consumption. 
Wear comfortable shoes and clothing for riding a bike. 
On the day of the test report to Reception, Level 2, Suite 26 of the Wesley Medical Centre at the appointed time. A doctor will be present for the testing.
Allergen Skin Prick Test
72 hours before test - do not take antihistamines 
Note: Mood stabilisers (e.g., Endep, Avanza) can cause a false negative test. Please inform staff when making your booking if you are taking prednisolone.

Respiratory and Sleep Specialists
To book appointments with a Respiratory Physician please call one of the following numbers. 
Locations can be found at our website www.qldrespiratory.com.au

Dr Farzad Bashirzadeh	(07)	3871 0033	Dr Justin Hundloe	(07) 3214 4000	
Dr Ian Brown	(07)	3832 7776	Dr Charl Liebenberg	(07) 4153 9414	
Dr David Deller	(07)	5539 4676	Dr Lee Rafter	(07) 4688 5480	
Dr Iain Feather	(07)	5597 1622	Dr Alex Ritchie	(07) 3832 7776	
Dr Maurice Heiner	(07)	3870 4511	Dr Chris Zappala	(07) 3371 0500	

QIP Accredited RSHQ Spirometry Provider