Gipping Respiratory Screening Questionnaire

Please complete the questions below.The questionnaire will be held with your confidential health records. This assessment is part of a health surveillance programme. As part of that programme the outcome of this assessment will be provided to the management to ensure continued protection of your respiratory function.

To record an accurate respiratory test it is IMPORTANT that you refrain from smoking and avoid drinks containing caffeine at least an hour prior to the test. If you are a known asthmatic or take regular medication please advise the occupational health advisor, on the day of your test, the name and dosage of the medication you take.

Please arrive 5 minutes before the appointment time.

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