Pulmonary Rehabilitation Referral
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Pulmonary Rehabilitation – Referral Form
Referrals Accepted from:
• GP
• Practice Nurse
• Community Matron
• Rapid Response Team
Suitability For Pulmonary Rehabilitation
-----------------------
Patient Details:
Surname: …………………………….. Forename ………………………… D.O.B ………………
Address: ……………………………... Hospital No: ………………………
NHS No:………………………
Chest Consultant: ……………………………………………
(if applicable)
Tel No: ………………………………
Clinical Details:
Diagnosis: ………………………………
Past Medical History: Medication:
Allergies:
Oxygen Therapy (Please circle): Nil Short Burst LTOT Ambulatory
Spirometry: Date: Attach Copy of Recent Spirometry
FEV1: Predicted.............% Will be reviewed by a Consultant before
FVC: acceptance onto course.
FEV1/FVC:
MRC dyspnoea scale (please circle): 1 / 2 / 3 / 4 / 5
1) I only get breathless with strenuous exercise
2) I only get short of breath when hurrying on the level or walking uphill
3) I walk slower than people of the same age on the level because of my breathlessness or have to stop for breath when walking at my own pace on the level
4) I stop for breath after walking 100 yards or after a few minutes on the level
5) I am too breathless to leave the house, or am breathless on dressing or undressing
(Ask the patient which best describes them)
Pulmonary Rehabilitation may be appropriate if the patient has:
← Breathlessness that limits functional ability, secondary to a respiratory cause (usually a MRC 3 greater)
← COPD Diagnosis
← Optimised respiratory medical management, according to NICE guidance
( Consented to being referred and can commit to attending twice a week for 7 weeks
Inclusion Criteria:
Pulmonary Rehabilitation is not appropriate if the patient has significant co-morbidities that render them unable or unsafe to exercise
Please confirm below:
← No severe / uncontrolled Heart Failure
← No recent (within 3 months of completing treatment) or untreated Pulmonary TB
← No known uncontrolled Cardiac Arrhythmias / Angina
← No serious cardiac event within the past 6 weeks
← No chest pain at rest or on exertion
← No untreated / uncontrolled Epilepsy
← Able to walk 10m independently (with or without walking aids)
← No other medical problems which severely restrict exercise or compliance with the course e.g. Severe arthritis or Dementia
Referrer Details
Name........................................................................... Position......................................
Address.................................................................................................................................
Contact Number.......................................................................................
Signature............................................................ Date........................................................
................
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