Medical survey control card

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?

 

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