Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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)