Personal Information

Title*
Please select your title.

First Name*
Please enter your first name.

Middle Name
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Last Name*
Please enter your last name.

Date of Birth*
Please enter your date of birth.

Height
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Weight*
Please enter your weight.


Medicare Number*
Please enter your medicare number.

Ref#
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Expiry*
Enter month.

 *
Enter year.


Postal Address*
Please enter your postal address.

Suburb*
Please enter your suburb.

State*
Please select a state.

Postcode*
Please enter your postcode.


Next of Kin Name*
Please enter the next of kin's name.

Relationship*
Please enter the relationship of your next of kin.

Telephone 1*
Please enter the next of kin's phone number.

Telephone 2
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Respiratory Medications

Medication
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Time of Last Dose
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Other Medications
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Past Medical History / Symptoms

Have you been diagnosed with Asthma?*

Please select Yes or No.


Have you been diagnosed with Chronic Obstructive Pulmonary Disease (COPD)?*

Please select Yes or No.


Have you been diagnosed with any other lung diseases?*

Please select Yes or No.


Have you been diagnosed with Obstructive Sleep Apnoea?*

Please select Yes or No.


Have you been told you have a problem with your lungs?*

Please select Yes or No.


Have you had a previous lung function test?*

Please select Yes or No.

Were the results normal?*

Please select Yes or No.

 
Do you get short of breath?*

Please select an answer.


Do you experience a wheeze?*

Please select an answer.


Do you have a cough?*

Please select Yes or No.

If Yes, is it*

Please select an answer.


Are you a smoker?*

Please select Yes or No.

For how long have you smoked?*
Please enter a duration.

How many cigarettes per day do you smoke?*
Please answer this question.


Are you are an ex-smoker?*

Please select Yes or No.

When did you give up?*
Please answer this question.

How many cigarettes per day were you smoking?*
Please answer this question.


Have you had any recent infections or illness?*

Please select Yes or No.

What was it?*
Please answer the question.

 

Consent to Testing

I have read this information and had the opportunity to ask questions. I understand the test which will be performed and I have been made aware of the risks involved. I understand that CRS is a private practice and that I will incur a fee for this test, for which I accept liability for and will pay in accordance with the policy set by CRS. I consent to participate in this procedure. I understand that the signing of this form is voluntary and I am absolutely free to deny consent if I desire.*

Please tick the box below *
Please tick the box to continue.