Appendix 1: REFERRAL FORM - Pulmonary Rehab
Pulmonary Rehabilitation Patient Information
A program of exercise and education for people with lung disease
Place: Insert details
Co-ordinator: Insert details
Contact Phone No: Insert details
Times: Insert details
Length of Program: Insert details
Who Participates: Any person with lung disease who is breathless on daily activities.
Aims of the Program:
• Reduce breathlessness and fatigue
• Improve your ability to undertake daily activities
• Increase your strength and the distance you can walk.
• Improve your well being
• Increase your confidence and ability to cope.
• Keep you out of hospital.
First Visit: This will take about one hour. During this visit you will be assessed and the program explained to you in more detail. The assessment will include a simple walking test.
Classes:
• The exercise program will be designed for you based on your assessment. You will be exercising with a group of people who also have lung disease
• You will also be given a home exercise program to do on 2 or 3 other days per week to gain the maximum benefit.
• On completion of the program you will have another assessment and options available to continue exercising will be discussed
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