SPIROMETRY REFERRAL FORM - Fraser Health Authority

SITEDropInADDRESSPHONE NUMBERCLINIC/LABHOURSBOOKINGINFORMATIONSITEDropInADDRESSPHONE NUMBERCLINIC/LABHOURSBOOKINGINFORMATIONAbbotsfordRegional Hospitaland Cancer Center(ARHCC)No32900 Marshall RoadAbbotsford, BC V2S 0C2P: 604 851 4700 x 642328Tuesday – Friday0800-1700FAX requisition to604-851-4852Lion’s GateHospitalPulmonaryFunction LabNo231 East 15th StreetNorth Vancouver B.C.V7L 2L7P: 604-984-5888Monday – Friday0800 – 1700FAX requisitions to604-984-3766Burnaby HospitalNo3935 Kincaid StBurnaby BC V5G 2X6P: 604-431-2839PF LABMon-Fri 0700-1600Spirometry ClinicM,T,F 0900-1400W,Th 0900-1800Phone to bookappointment604-431-2839Lion’s GateHospital PortableClinicNoc/o 231 East 15 th StreetNorth Vancouver B.C.V7L 2L7P: 604-984-5888RT available to testin GP offices 1day/weekBarb Moore, RRT:604-988-3311ext. 4954Chilliwack GeneralHospitalNo45600 Menholm RoadChilliwack, BC V2P 1P7P: 604-795-4141 x 614254Monday – Friday0800-1600FAX requisition to604-795-4161Mount St JosephHospitalNo3080 Prince Edward St.Vancouver, BC V5T 3N4P: 604-877-8528Monday – Friday0900 – 1700FAX requisitions tocentral fax number,604-806-8544Delta HospitalNo5800 Mountain View BlvdDelta, BC V4K 3V6P: 604-946-1121x 3523Monday – Friday0900-1600OccasionalSaturdays andeveningsFAX requisition to604-952-7353Richmond HospitalNo7000 Westminster HighwayRichmond, BC V6X 1A2FAX 604-244-5274Tuesday – Friday0800 – 1700Phone to bookappointmentP: 604-244-5124Eagle RidgeHospitalNo475 Guildford WayPort Moody, BC V3H 3W9P: 604-469-31752 appointments dailyMon - FriFAX requisition to604-469-3220St Paul’s HospitalSt Paul’s HospitalDrop in SessionsNoYES1081 Burrard St.Vancouver, BC V6Z 1Y6P: 604-806-83331081 Burrard St.Vancouver, BC V6Z 1Y6P: 604-806-8333Monday – Friday0800 – 1600Monday – Friday1245 – 1530FAX requisitions tocentral fax number,604-806-8544Drop in Only – pleasebring requisition formLangley MemorialHospitalNo22051 Fraser HwyLangley, BC V3A 4H4P: 604-514-6081Monday-Thursday1100-1430Fri 0800-1430FAX requisition to604-533-6454UBC HospitalNoKoerner PavilionS103 2 nd Floor2211 Westbrook MallVancouver BC V6T 2B5F: 604-822-7903Tuesday – Thursday0830 – 1800Phone to bookappointmentP: 604-822-7255Mission MemorialHospitalPeace ArchHospitalNoNo7324 Hurd StreetMission, BC V2V 3H5P: 604-814-51761552 Russell AveWhite Rock, BC V4B 2R4P: 604-535-4500 x 757226Monday – Friday1000-1500Monday-Friday0800-1630FAX requisition to604-820-8730FAX requisition to604-541-5867UBC Drop inBusiness hoursUBC Drop inAfter hours,weekendsYESYESKoerner Pavilion S103 2 nd Floor2211 Westbrook MallVancouver, BC V6T 2B5P: 604-822-7903Urgent Care Centre2211 Westbrook MallVancouver, BC V6T 2B5Monday – Friday0800 – 1600Monday – Friday1600 – 2100Saturday & Sunday0800 – 2100Drop in – please bringrequisition formDrop in – please bringrequisition formRidge MeadowsHospitalNo11666 Laity StreetMaple Ridge, BC V2X 7G5F: 604-463-1887Monday - Friday0700 - 1900Phone 604-463-1820to book appointmentsVGH Lung CenterSpirometry Drop InYESGordon & Leslie DiamondHealth Care Centre, 7 th Floor2775 Laurel St.Vancouver, BC V5Z 1M9P: 604-875-4324F: 604-875-4695Tuesday – Friday0830 – 12001230 – 1600Drop in only – pleasebring requisition formRoyal ColumbianHospitalSurrey MemorialHospitalCharles BarhamPavilionEnter from 94A AveNoNo330 E Columbia StreetNew Westminster, BC V3L 3W7P: 604-520-403513750 96 AvenueSurrey, BC V3V 1Z2P: 604-585-5970Mon- Th 0630-1900Fri 0630-1700Some Saturdays andSundays 0700-1900Mon-Fri 0800-1800Some Saturdays0830-1600FAX requisition to604-520-4910FAX requisition to604-585-5922VGH PulmonaryFunction LabDrop in SessionsVGH PulmonaryFunction LabYESNoCentennial PavilionGround Floor899 West 12 th Ave.Vancouver, BC V5Z 1M9P: 604-875-4830F: 604-875-5695Centennial Pavilion G-Floor899 West 12 th Ave.Vancouver, BC V5Z 1M9P: 604-875-4830F: 604-875-5695Drop in ONLY:Mon 1230 – 1530Wed 0930 – 1200Monday – Friday8:00 – 1700Drop in only - pleasebring requisition formPhone to bookappointmentP: 604-875-5695VCH.0029 Jan.2009

COPD Management Services Referral FormPatient Name:PHN:Phone (Home):(Work):Address: (include Postal code)DOB: (yy/mm/dd)Family Doctor:Fax:Phone:Sex:Respirologist:Fax:Phone:Reason for Referral/Comments:Recent ED Visit Recent Hospital Admission New or suspected diagnosis of COPDEducation requiredOther: _____________________________________________________Preferred Program:Self Management Education Pulmonary Rehabilitation Maintenance Exercise COPD Clinic(education & exercise) (rehab graduates only) (respirologist visit)Medications:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Relevant History:Cardiac disease Neurological deficits Arthritis Other: ______________________________________________________________________________________________________________Does your patient have any pre-existing health condition that would make exercise unsafe?NO Yes Specify __________________________________________________________________REFERRING PHYSICIAN NAME: ___________________________________________________________REFERRING PHYSICIAN SIGNATURE: ____________________________ DATE: ___________________Please complete referral form or CDM Patient Summary and attach copy of most recentSpirometry/PFT and Action Plan (if available).Fax to location of choice, see list on the back of this form. Please note: not all locationsprovide all services.For Rehab Referral send if available: recent spirometry, Chest X-ray, ECG, Hematology Panel,Exercise Oximetry, Stress test and any recent respirologist consult letter. If the required test isunavailable it may be ordered through the medical director of the rehab program.VCH.0030 Jan.2009

Pulmonary rehabilitation significantly improves dyspnea, exercise endurance, quality of life andrisk of hospitalizations following AECOPD. All Lower Mainland rehab programs providecomprehensive self management education and supervised exercise programs.Speciality COPD Clinics provide a multi disciplinary assessment and treatment plan forsuspected or confirmed COPD patients. These clinics include Respirologist consult and selfmanagement education.Locations Booking & Contact Info Services AvailableVancouverVancouver General Hospital FAX requisition to 604-875-5695Phone: 604-875-4830The Lung CentreVancouver General HospitalFAX requisiton to 604-875-4695Phone: 604-875-4122St. Paul’s Hospital FAX requisiton to 604-806-9143Phone: 604-806-8115St. Paul’s HospitalEducation CentrePacific Lung Health CentreSt. Paul’s HospitalFax requisition to 604-806-8544Phone: 604-806-8808FAX requisition to 604-806-8839Phone: 604-806-8818Kerrisdale Community Centre FAX requisition to 604-267-3993Phone: 604-267-4430West End Community Centre FAX requisition to 604-806-8839Phone: 604-806-8818Pulmonary RehabilitationMaintenance ExerciseCOPD Clinic (includes Respirologist consult andSelf Management Education)Pulmonary RehabilitationMaintenance ExerciseSelf Management EducationSmoking Cessation CounsellingCOPD Clinic ( includes Respirologist consult andSelf Management Education)Pulmonary RehabilitationMaintenance ExerciseMaintenance Exercise onlyNorth ShoreLions Gate Hospital FAX requisition to: 604:984-3766Phone: 604-984-5888RichmondGarratt Wellness Centre FAX requisition to 604-204-2017Phone: 604-204-2007Fraser Health AuthorityCommunity RespiratoryServices (in home service)Fraser NorthiConnect Health CentreNew WestminsterFAX requisition to 604-514-6079Phone: 604-514-6106FAX requisition to 604-523-8801Phone: 604-523-8800Ridge Meadows Hospital FAX requisition to 604-463-1887Phone: 604-463-1855Fraser SouthSurrey Memorial HospitalFAX requisition to 604-585-5922In hospital or YMCAPhone: 604-585-5570Langley Memorial Hospital FAX requisition to 604-533-6449Phone: 604-534-4121 ext 5273Fraser EastChilliwack General Hospital FAX requisition to 604-702-4709Phone: 604-795-4141 ext 614244Abbotsford Regional Hospital FAX requisition to 604-851-4774Phone: 604-851-4700 ext 642215Self Management EducationPulmonary RehabilitationMaintenance ExerciseCOPD Clinic (includes Respirologist consult andSelf Management Education)Smoking Cessation CounsellingSelf Management EducationPulmonary RehabilitationSelf Management EducationSelf Management EducationPulmonary RehabilitationMaintenance ExerciseCOPD Clinic ( includes Respirologist consult andSelf Management Education)Smoking Cessation CounsellingPulmonary RehabilitationMaintenance for O2 dependant patientsSmoking Cessation CounsellingPulmonary RehabilitationMaintenance ExercisePulmonary RehabilitationMaintenance ExerciseSelf Management EducationPulmonary RehabilitationMaintenance ExerciseSelf Management EducationVCH.0030 Jan.2009

COPD ACTION PLANPatient Name: ___________________________ Date: ________________________________PHN: __________________________________ Date of Birth: __________________________Family Contact: __________________________ Phone #: _____________________________Physician: ______________________________ Phone #: _____________________________After Hours Phone #: ___________________________________________________________You have been diagnosed with Chronic Obstructive Pulmonary Disease (COPD). As someone withCOPD, you are either in your stable, everyday state or having a flare up. This Flare up Plan is a writtencontract between you and your doctor about how you will manage your COPD flare ups. This Plan willhelp you and your doctor to quickly recognize and treat flare ups to improve your health.COPD (chronic obstructive pulmonary disease) has 2 states:When you are stable:1. Breathing without shortness of breath2. Able to do daily activities3. Mucous is easy to cough up4. Sleep well5. Able to exercise as directed by physicianHow to tell if you are having a flare upA flare up may occur after you get a cold, get run down or are exposed to air pollution or very hot orcold weather. There are 3 things that define a flare up:1. Increased shortness of breath from your usual level2. Increased amount of sputum from your normal level3. Sputum changes from its normal colour to yellow, green or rust colourSome people may feel a change in mood, fatigue or low energy prior to a flare-up.If any 2 or all of these symptoms persist for 48 or more hours do the following:(Your physician will check the desired action plan for you)□ Take your rescue inhaler 2-4 puffs as needed (up to 4-6 times per day) for shortness of breath.□ Contact your family doctor immediately for a check up and medication review.□ Take your prescribed antibiotic for a COPD flare up (see over).□ Take your prescribed prednisone for a COPD flare up (see over).□ Contact your doctor if you feel worse or do not feel better after 48 hours of treatment.□ Other ______________________________________________________________________If you are extremely breathless, anxious, fearful, drowsy or having chest pain,call 911 for an ambulance to take you to the emergency room.Physician Signature________________________________________________Patient/Caregiver Signature__________________________________________ Please turn over

COPD MAINTENANCE MEDICATION RECORDPatient Name: ___________________________ Date: ________________________________PHN: __________________________________ Date of Birth: __________________________Family Contact: __________________________ Phone #: _____________________________Physician: ______________________________ Phone #: _____________________________After Hours Phone #: ___________________________________________________________Patients: Take the following maintenance medications every day to help maintain control of yourCOPD symptoms.Physicians: Please fill in prescribed maintenance medications.Medication PrescribedHow Much toTakeWhen To TakeCOPD FLARE-UP MEDICATION RECORDPatients: Please fill in date when you start and finish your flare-up medications.Physicians: Please fill in prescribed flare-up (antibiotics & prednisone) medications.Medication Prescribed Start Date /Finish DateStart Date /Finish DateStart Date /Finish DateMake sure to take prescribed medication until all finished.

AVOIDLUNGATTACKSLUNG ATTACKS:The # 1 reason for hospitalizations in BCLung attacks often happen to people who have not yet been diagnosed with chronic obstructivepulmonary disease (COPD). A simple breathing test can identify your risk for COPDand prevent a COPD flare-up.Who should have a breathing test?People 40+ years of age who are current or ex-smokersand answer YES to any of the following questions:• Do you cough regularly?• Do you cough up phlegm regularly?• Do even simple chores make you short of breath?• Do you wheeze when you exert yourself, or at night?• Do you get frequent colds that persist longer than thoseof other people?Ask your doctor if you shouldhave a breathing test!For more information about COPD visit www.bclung.ca