Significant Medical Conditions:

Please attach Consultants summary sheet of current problems, past medical history and current medications if available, please note that













Any other information









Date of referral: ..../........../...

Patients Name Male / Female (please circle as appropriate)


Current Address *




Age
DOB .../....../......
Phone
Consultant

Speciality
Consultant Tel No
FAX
No
Date last seen by
Consultant

....../......./.......
Emergency Contact:-
Name Phone No

Relationship


CONSENT TO SHARE YES NO

All long term conditions that relate to patient - tick all that apply
COPD Angina/CHD UTI and/or urinary problems Medication problems
Asthma Heart failure Falls Stroke - prevention only
Diabetes Other needs
PULMONARY REHABILITATION FORM

On LTOT Yes/
No
Ambulatory
O2
Yes/No
Has the patient had an ambulatory oxygen assessment
Yes/ No


Smoking

yes/ no/ ex
Previous type
II failure

yes/no
Is the patient hypertensive?
Yes/ No Normal resting
B/P
Does the patient suffer form dizziness
Yes/ no

If present has dizziness been investigated:
yes/ no Date

Has chest pain yes/ no


If present has chest pain been
investigated:

Yes/No Date:
GTN usage

Yes/No Comments
Previous Pulmonary
rehabilitation

Yes (when ..)/ No
Previous Admissions: In last year


In last 5 years
Spirometry Date:

FEV1 .. % predicted, FVC .% predicted ratio%


Does the patient have any serious mobility problems, or severe arthritic limitations to exercise, or other
limitations to exercise e.g. CVA, Amputation etc??

Yes/ No If yes please state limitation..

Completed by Designation


Contact Address and Number


Date Completed



Inclusion Criteria Pulmonary Rehabilitation
Diagnosed respiratory condition and consider themselves to be functionally limited by their disease, usually borg
dyspnoea score more than 4
Bronchiectasis, recovering chest trauma and pre / post lung resection also considered.

Exclusion from pulmonary rehabilitation:
Patients with unstable angina, unresolved chest pain or Myocardial Infarction within the last 3 months
Patients with severe cardiac arrhythmias/ uncontrolled arrhythmia
History of cardiac arrest
Implantable cardioverter defibrillator in situ
Acute congestive heart failure
Aortic stenosis
Recent systemic or pulmonary embolus
Patients with uncontrolled medical co-morbidities or major surgery within the last 3 months
Patients with uncompensated heart failure = decreased systolic BP of 15mmHg during exercise or failure of systolic
BP to rise consistently with exercise
Hypertension > 180mm Hg systolic / 95mm Hg diastolic
Hypoxia of below 92% on air at rest, unless patient has supplemental oxygen therapy


For clinical enquiries please telephone physiotherapy services on department 9818911195

Please ensure that you provide ALL the information required so we can safely assess your patients
suitability.



Dr. B. L. Kapur Memorial Hospital, Pusa Road, New Delhi -110005
Tel: +91 11 3040 3040, Ambulance Helpline: +91 11 3065 3030

BLK/RHM/07/00/2012