1. UNIVERSITY MEDICAL ASSOCIATES P.S.C
DIVISION OF PULMONARY, CRITICAL CARE
& SLEEP DISORDERS MEDICINE
401 EAST CHESTNUT ST. SUITE 310
LOUISVILLE, KY 40202
Located at the UofL Healthcare Outpatient Center
PHONE (502) 855-7856 F AX ( 502 ) 8 13- 63 89
* PLEASE ATTACH RECENT PATIENT DEMOGRAPHICS & INSURANCE INFORMATION TO EXPEDITE SCHEDULING*
Patient Name: ____ D.O.B: ___
Home Phone: __ Work Phone: ___ Cell Phone: ___
DIAGNOSES:_____________________________________________________________________________________
Please provide the diagnoses (signs, symptoms, reason for referral) including codes, and other pertinent clinical information.
WHERE WOULD YOU LIKE THE RESULTS TO BE SENT UPON COMPLETION? *Default is sent to ordering physician*
Fax: ___ E-Mail:  Mailing Address:
 Today ( if schedule permits )  To be scheduled _______ _______
PUMONARY FUNCTION TESTING FUNCTIONAL CAPACITY
 Complete PFTs + Pre & Post Bronchodilator Testing  6 Minute Walk Test (following ATS standards)
CPP
SIX
(spirometry, lung volumes and DLCO (albuterol 2.5 mg nebulizer)
 Multiple Pulse Oximetry Test MPO
 Complete PFTs (spirometry, lung volumes and DLCO) CDL
 Multiple Pulse Oximetry Test with POO
 Spirometry (includes flow-volume loop and MVV) FVL
Oxygen Titration
 Spirometry + Pre & Post Bronchodilator Testing SPP
 Cardiopulmonary Exercise Testing EXT
(albuterol 2.5 mg nebulizer)
 Lung Volumes (TLC, FRC, RV, VC, etc.) TLC
 Carbon Monoxide Diffusing Capacity (DLCO) DLC
 Maximum Inspiratory and Expiratory Pressures (MIP / MEP) MIP
BRONCHIAL HYGIENE & MAINTENANCE ADDITIONAL TESTING
 Small Volume Nebulizer Treatment  Methacholine Challenge Testing (asthma
SVN MCH
 Albuterol 2.5 mg evaluation)
 Levalbuterol (Circle: 1.25 mg, 0.63 mg)  Arterial Blood Gas ABG
 Ipratropium Bromide (Atrovent) 0.5 mg CIRCLE: room air or supp O2 ___________l/min)
 Induced Sputum with hypertonic saline SNA  Today  Scheduled
 Nasal Tracheal Suctioning NSX  Exercise-induced Bronchospasm EIB
 One on One Patient Education PED  Over Night Oximetry Study ONO
 Deep Breath & Cough  Exhaled Nitric Oxide
 Purse Lip Breathing  Transcutaneous hemoglobin
 MDI and Medication Instruction and Techniques measurement
 Other:
Comments: _____
__________________________________________________________________________ _____
Name of Practice/Medical Facility: _____
Referring Physician: Date: ______
Ordering Physician: NPI #: Date: ______
Order Form rev 2009–09-17 ver 8