Spirometry Assessment Checklist

If you have been advised by the surgery to submit a spirometry checklist, please submit this form.

Spirometry Assessment
Registered practice: *


Smoking status:
How many do you smoke per day?
Are you taking any inhalers?

Do you have any of the following:

Bladder problems: *
MI (Heart Attack) in the last 6 weeks: *
Current haemoptysis (coughing up blood) of unknown origin: *
Post pneumothorax (collapsed lung) in the last 6 weeks: *
Aortic Aneurysm: *
Post eye surgery in the last 6 weeks: *
Chest/abdominal surgery in the last 6 weeks: *
Known or suspected lung TB (Tuberculosis): *
Recent vomiting/diarrhoea (in the last 48 hours): *
Exacerbation (Chest infection needing antibiotics in the last 6 weeks): *
COVID symptoms or positive COVID test in the last 4 weeks: *