Subject ID | Name | Birthdate | |||||||||
Age | Gender M F | Ethnicity (Hispanic) Y N | Race AmIn As Bl PI Wh | Smoke C F N | |||||||
Height (nearest ½ inch) | Weight (pounds) | Blood Pressure | Pulse
| ||||||||
Current Medications/Eye Drops/Inhalers | |||||||||||
INITIAL WHEN COMPLETE | Questionnaire | FENO | Multiple-Breath Washout | ||||||||
IOS | Spirometry | Bronchodilator | Color Vision Testing |
Spirometry Contraindications: YES / NO Within the last 3 months: chest pain (angina), heart attack, stroke , eye surgery (including LASIK, PRK, or cataract surgery), chest surgery (including heart procedure), abdominal surgery, and head surgery (including brain or ear surgery). Ever: coughing up blood (hemoptysis), collapsed lung (pneumothorax), arterial aneurysm of the belly or brain, or detached retina Current: gastrointestinal distress, chest discomfort, back discomfort, treatment (anticoagulant) for pulmonary embolism, require supplemental oxygen Systolic BP >180, diastolic BP >110, pulse >110 bpm |
Bronchodilator Contraindications: YES / NO Have you ever been diagnosed by a healthcare professional with an irregular heart beat (arrhythmia) Have you ever had a seizure? Have you ever had an adverse reaction to albuterol such as tremors, palpitations, fast heart rate, hypertension, fainting, dizziness, headache, upset stomach, or skin rashes Systolic BP >160, diastolic BP >100 Pulse >100 bpm Physician’s signature:______________________________________________ FeNO Contraindications: YES / NO Do you have a breathing problem requiring oxygen or problems taking deep breaths? |
File Type | application/vnd.openxmlformats-officedocument.presentationml.presentation |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |