Pulmonary Rehabilitation for COPD



|Office use only: |

|Accepted |

|Patient Refused |

|Not Suitable |

|CRN: |

|      |

Thank you for referring your patient to the Suffolk COPD Services Pulmonary Rehabilitation Programme.

Please make sure all the form is completed.

Referral criteria and further details are available on our website

|Patient Details |

|Name: Forename Surname NHS No: NHS number |

|Address: Patient address house Patient address road DOB: Date of birth |

|Patient address post town |

|Postcode: Patient post code |

|Tel Nos: Home: Patient home telephone number Mobile: Patient mobile telephone number |

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|GP Details |

|Name: |

|Surgery Address: Sender address building Sender address post town |

|Patient diagnosed with COPD Yes No |

| |

|Relevant Medical History/Past Medical History /co-morbidities:- |

|      |

|Current Medication (list may be attached) |

|Current Issues |

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|Current home oxygen therapy Yes No |

|Spirometry |FEV1 |      | |

|Date performed: | | | |

| |FVC |      | |

| |FEV1/FVC |      | |

| |SpO2 |      | |

|MRC |      |Distance able to mobilise?       |

| | |Walking aids required?       |

|Smoking History and status (pack years)       |

|Smoking cessation offered?       |

|Patient’s Preferred Site: Patient will require access to transport to attend course venues. |

|Hospital |

|Closer to Home Patients preferred location |

|Either |

|I confirm the patient’s condition is optimally controlled: |

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|I confirm I have checked the following criteria (see website): |

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|exclusion criteria inclusion criteria |

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|I confirm the patient is motivated to take part in pulmonary rehab: |

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|Consider referral for 1:1 if severely limiting musculoskeletal/neurological/psychiatric conditions |

|uncomfortable with group work. Please contact service direct. |

|Any Additional Information (eg: sleep, sputum clearance, diet): |

|      |

|Interpretation/signer required? Yes No (If yes please specify which language) |

|Person Referring:       Position:       |

|Contact Details:       Date:       |

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