John F. Zwetchkenbaum, M.D.

Barrie L, Weisman, M.D.

Toby F. Weiser, PA-C

Methacholine Challenge Test

Pretest lnstructions:

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Please allow about one (1) hour to conrplete the test.

Do not eat or drink anything with caffeine (coftee, soda, chocolate)
16 hours prior to testing.
Do not smoke six (6) hours prior testing.
If you have any respiratory symptoms on the day of your test, inform
the technician prior testing.
Do not take anybreathing medication before the test as directed

below:

Serevent, Foradil, Advair, Slo-bid, theo-Z4, Spriiva, Uniphyl,

Dilor, Dilex, or other Theophylline contai nngproducts, should
be held for 48 hours prior to appoinfinent.

o Albuterol, Ventolin, Proventil,Maxar, Alupent, Annaeort,

Flovent, Pulmicort, Aerobid, Q-var, and Atrovent should be
held for 12 hours prior to appointment.

Important hlote:
If for some reason you arc vnable to make your
appoinftnent, please notify the office 24 hours prior
to visit. Methacholine has a very short shelf life and must
be discarded if not used. It is preparcd on the day of
testing by the technician, therefore, if a Z4-haur notice is
not given, you will be billed $100 for the cost of the
medication and preparation for testing.

1056 Hope Street, Frovidence, RI 02906 * Phone (401)751-1235 * Fax (401)75147U

*
2 Wake Robin Roa4 Suite 201, Lincoln" RI 02865 * Phone (401) 334-0410 Fax (AD $3-3925
*
*
1180 Hope Sfieet, Bristol, RI02809 Phone (401)751-1235 Fax @AD253'3131

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John F. Zwetsl*enbaunn, M.D.

BarrieL. Weisma&M,D.
Toby F. lVeiser, pA-C

Methacholine Challenge Consent

Procedure:
The purpgse

9f a Metlncholine Chatlenge test is to determine the amount of

ainvay funtability of a patient. You, or your chil4 will be asked tp inhalc a
mist that contains different concentrations for Methacholine. The mist is
produced by adevice called a nebulizer and intraled through a mouthpiece
or facemask Before the test begins, and aftsreach period-of inhalatioi, you
or you child urill be asked to blow forcefully into a Spirometer. The test
usually takes about an hour.

Discomforts and Risla:

asthma attack but the inhalation of aerosols
myvb;9 associated with mild shorfiress of breath, cough, chest tightness,
wheer-ing, chest soreness, or headache.Many patients do not tave any
symptoms at all. These slmnptoms, ifthey occur, are mitd, Iast for only a
few minutes, and disappear followiag the inhatation of a bronchodilator
medication. There is a very small possiUitity of severe narrowing of your
airways. This could cause severe shortness of breath, if this occtrs, you will
be immediately freated.

Itnve rcadthe

above information and understand the purpose of the test and

ttre associated risks. With this knowledge,I agreeto have this test performed
on my child or me.

atient Name : (rlease prinQ

Patient or Gu ardian signature

Witness by:
Date,:

i phone (4ol)7st-1235 + Fax (4ot)7st4744

!055 Hope street, Providence, Rr 02906
2 Wake Robin Road, suite 201, Lincoln, RI 02865 * phone (401) 334-ul0 * For (401) 333-3925
I180 Hope street, Bristol, RI02809 * phone (Nt)7s1.1235 i Fax lngzsl-ztst