CQRASC Contraindications For Performing Spirometry "*" indicates required fields Patient Name* Name Patient DOB* DD slash MM slash YYYY Date* DD slash MM slash YYYY Do you have or have you ever had? (Yes or No)Any current respiratory symptoms such as fever, runny nose, sore throat, cough, loss of smell/taste.* Yes No Comment/Unknown*Recent contact with suspected or confirmed COVID-19 case.* Yes No Comment/Unknown*Hypertension -resting blood pressure greater than 160/100mHg.* Yes No Comment/Unknown*Unstable cardiovascular status or chest pain within the last 6 months.* Yes No Comment/Unknown*Unstable angina in the past month.* Yes No Comment/Unknown*Recent myocardial infarction (heart attack) within the last 6 months.* Yes No Comment/Unknown*Recent pulmonary embolism (lung clot) in the last 6 months.* Yes No Comment/Unknown*Recently collapsed lung in the last 6 weeks.* Yes No Comment/Unknown*Haemoptysis (coughing blood).* Yes No Comment/Unknown*Chest, abdominal or Brain aneurysms.* Yes No Comment/Unknown*Aortic dissection.* Yes No Comment/Unknown*Recent surgery (Including the Eye).* Yes No Comment/Unknown*Recent Nausea, Vomiting or Diarrhea.* Yes No Comment/Unknown*Cognitive Impairment or Dementia.* Yes No Comment/Unknown*Further information may be required if you have answered yes to any of the previous questions.Date* DD slash MM slash YYYY Patient Signature*
