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Patient Label
Referral Source:
___________________________
Assessment Date:
___________________________
Or
Name: _____________________ D.O.B. __________
Respiratory Therapist:
_____________________
Last,First Middle
dd/mm/yy
REASON FOR REFERRAL/VISIT
 Home-based Respiratory follow-up
 COPD self-management education
 Advance care planning
 Oxygen Assessment
 Other: __________________________________________________________________________________________
HISTORY - Advanced COPD as per INSPIRED eligibility criteria and:






GERD
Bronchiectasis
Restrictive disorder
Asthma
CHF
Heart Disease ______________
 Pulmonary Hypertension
 Cancer _______________________
 Diabetes
 CVA
 Neuromuscular disease
 Other: ______________________
________________________________
 Family History: ____________
________________________________
________________________________
 Occupational History: _______
________________________________
________________________________
RELEVANT SURGERIES
SMOKING HISTORY
Current:
 N  Y  Never
Quit:
 N
 Y Date: __________________
# Years Smoking: __________
Quantity (ppd/PackYears) _________
Type of Tobacco: cigarettes cigars pipe other _________
2nd hand smoke:
 N
 Y
( current  past)
 Other details:___________________________________________________________________________________
DIAGNOTIC TEST RESULTS/VACCINATIONS
Previous Pulmonary Education/Rehabilitation:
 N
 Y Date/Details: _________________________
Pulmonary Function Tests confirming Dx:
 N
 Y Date/Results: __________________________
Significant results on Chest X-ray/Scan:
 N
 Y Date/Results: __________________________
Vaccinations:
influenza
 N
 Y Date: __________________________________
pneumococcal
 N
 Y Date: __________________________________
Other: ____________________________________________________________________________________________
MOBILITY/ADLs/ENVIRONMENTAL CONCERNS
Mobility Support:  cane  walker
 wheelchair  other: ____________________
Stairs into home:  N
 Y
Within home:  N  Y
Environmental Concerns: ____________________
____________________________________________
Other relevant information:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
SLEEP
Usual Hours or Sleep: ________
Insomnia:
 N  Y
Daytime Hypersomnia:
 N  Y
Rested:
 N  Y
Snoring:
 N  Y
Apnea:
 N  Y
Nocturnal Dyspnea:
 N  Y
Nocturnal Cough:  N  Y
Morning Headache:
 N  Y
Nightmare/restlessness: N  Y
Sleep Aids:
 N  Y
Orthopnea:
 N  Y
# pillows or  elevation:________
Awake for MDI:
 N  Y
Time: __________
CPAP/BiPAP:  N  Y Pressure: _________
Nocturnal Oxygen:  N  Y Flow:___________
Other:
___________________________________________________________________________________________________
CARDIOVASCULAR
Pain:  N  Y
 sharp  dull Site: ________ Palpitations:  N  Y
Pacemaker:  N Y
Vertigo:  N  Y Edema:  N  Y
Site/degree: _____________________________________________
Fluid Restriction:  N  Y Special Diet:  N  Y
Weight:  stable  increased  decreased
Other: ___________________________________________________________________________________________
CLINICAL DATA
Oximetry site: ____________
Rest
BP:
________
Room Air
ADL
Temp:
_______
______ post
Position:
Rest
___________
O2 (____ lpm/FiO2)
ADL
______ post
SpO2
HR
RR
Distance/ADL
Exertional
Time
Resp
effort/pattern
Recovery Time
ABG: pH______ PaCO2______
Date: ______________
HCO3______
SaO2______
FiO2/lpm______
Hgb ______
Site: ________
RESPIRATORY ASSESSMENT
Notes: ____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
MEDICATIONS
Notes: ____________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
GENERAL COMMENTS/NOTES FOR CLINICIAN
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date:
_________________________________
Signature:
________________________________________
(Registered Respiratory Therapist)
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