ATS Pulmonary Function Laboratory Manual

ATS Pulmonary Function Laboratory Management & Procedure Manual | 3rd Edition

Appendix 19.1  Example of Pre-Exercise Test Questionnaire Name:

ID No.:

Date:

Test Indication:

Ordering M.D.:

Medications (include time last taken and dose) Chest Pain: Yes No If yes, when: Do you use oxygen? Yes No Usage:

Medical History: Cardiac History: Smoking History: When and what did you last eat? Exercise Toler ance: Can walk

steps/…ights of stairs without resting

Can walk blocks without resting Can run/walk miles without resting ( Regular exercise or activity includes: Comments: Name of individual completing questionnaire:

minutes per mile)

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