Spirometry consent form

HFGP Consent Form for Spirometry

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Spirometry is a breathing test used to assess how well your lungs are functioning. It measures the amount of air you can breathe in and out and how quickly you can exhale.

The test requires you to take a deep breath in and then blow out as hard and as fast as possible into a mouthpiece several times.

Bronchodilator Testing

Your doctor may request pre- and post-bronchodilator spirometry.

This involves:

Initial spirometry testing.
Administration of a bronchodilator inhaler (usually salbutamol/Ventolin®).
Waiting approximately 10 to 15 minutes.
Repeating the spirometry test.

This helps assess whether your airways respond to bronchodilator medication.

All procedures have risks and side effects. It is important that you understand the specific side effects of any treatment/procedure/test

Please read and cross the below statements to indicate that you have been told of these side effects and understand their implications.

Serious reactions are extremely uncommon. Emergency equipment and trained staff are available should an unexpected reaction occur.

Possible Risks and Side Effects

Spirometry is generally very safe; however, it may occasionally cause:

Temporary dizziness or light-headedness
Shortness of breath or coughing
Chest discomfort
Fatigue from repeated breathing manoeuvres

Possible side effects from bronchodilator medication:

Tremor or shakiness
Palpitations or awareness of heartbeat
Mild headache
Nervousness or feeling jittery
Temporary increase in heart rate

I confirm I have read the above. My treating Doctor has discussed with me the benefits, risks and side effects *

Contraindications and Safety Screening

Spirometry may not be suitable in certain situations because forceful breathing can place strain on the chest, eyes, abdomen, blood vessels, and recent surgical sites.

Contraindications and Safety Screening

Please indicate below and advise staff if any of the following apply: *

Heart attack, unstable heart condition, or stroke within the last 4 weeksRecent eye, chest, abdominal, or brain surgeryCollapsed lung (pneumothorax)Coughing up blood of unknown causeSevere respiratory infection or suspected tuberculosisA condition where forceful blowing has been advised against by your doctor (e.g. aneurysm or recent significant injury)None of the above apply

I have discussed with my doctor and understand the fees involved, which includes the cost, rebate and out of pocket expense, of the procedure *

I have read and understood the information provided, have had the opportunity to ask questions, understand the costs and potential risks, and consent to spirometry testing (including bronchodilator testing if clinically indicated).

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