[PLEASE REVIEW AND UPDATE AS APPROPRIATE TO YOUR SERVICE] Pulmonary Rehabilitation Patient Record Patient ID or Patient name: ……………….………. Consultant/Therapist: Consent form signed Medication recorded Questionnaires returned DOB: .……….…………………….……… Male/Female: ……………….……… NHS number:…..…………….………. PATIENT DETAILS Patient Address: GP Name and address: Postcode: GP Postcode: Telephone (day): GP telephone Mobile: Next of Kin NoK telephone Interpreter required? YES NO Relationship to patient Languages spoken English Welsh Hindi Bengali Urdu Punjabi Gujarati Other: Ethnicity: □ White British □ White Irish □ Any other White background □ Caribbean □ African □ White and Black Caribbean □ White and Black African □ Any other Black background □ Indian □ Pakistani □ Bangladeshi □ White and Asian □ Any other Asian background □ Chinese □ Any other ethnic group □ Any mixed background □ Not stated Web access and web literacy Access to internet at home and confident using Access to internet at elsewhere and confident using Access to internet with assistance No access/not web literate Housing Stairs Stair Lift House / Flat / Bungalow YES NO YES NO Employment status Full-time Part-time Unemployed Retired Other: Social Circumstances Lives alone Lives with spouse/partner with family Occupation Age when left education? Requires Transport? YES NO Patient is a carer? Pt dependent on carer? YES NO YES NO MRSA: +ve -ve Risk Factor: Yes / No Site: Sputum Wound Flaking Skin Previous MRSA Contact: Yes / No (if answer is yes to any question then please fill in MRSA screening tool)
REFERRAL & ASSESSMENT Date of receipt of referral: Initial Assessment date: Referral pathway: Elective Post-AECOPD Other: Referred from: Secondary Care GP/practice team Community Services Referred by: Consultant/clinical team Specialist COPD team GP Nurse Other: PR start date offered? Yes No If no, what was the reason? Clinically unsuitable Patient declined Patient unable to attend Not recorded If yes, PR start date: Number of sessions scheduled: Number of sessions completed: Type of Programme: Rolling Cohort Other Site/Venue: [Site A] [Site B] [Site C] Previously attended a PR programme in the last year? YES NO If yes, completed programme? YES NO Supplemental oxygen given during exercise Yes No Main Diagnosis COPD Asthma Alpha 1 antitrypsin deficiency Bronchiectasis Hyperventilation Respiratory Failure PCD Dysfunctional Breathing Lung Cancer ABPA Pneumonia Hyperventilation OSA IPF IP (Idiopathic Interstitial Pneumonia) NSIP Sarcoidosis ILD (Interstitial Lung Disease) HP (Hypersensitivity Pneumonitis) unknown/other Significant Comorbidities Vascular size ……... TIA CKD CVA Metabolic I disease Diabetes II Cachexia Obesity M/S (UL or LL) (UL/LL) R/A CFS(Chronic Fatigue Syndrome) LBP(Lower back pain) A/S(Ankylosing Spondylitis)
Cardiac MVD AVD Congenital Heart Angina Heart Failure Severity……………… MVR AVR Pulmonary Hypertension Atrial Fibrillation CHD Arrest angina stenosis Severity……………….. Neurological Parkinsons Epilepsy Infectious Diseases Catarrhalis) HIV Hepatitis GI Hernia Diverticulitis Ulcerative colitis Crohns Disease Cancers Yes No Please specify:……………………… Psychiatric disorder Depression Dementia/Alzheimer’s Falls in last year Yes No If Yes, how many? ………………………… Cognitive impairment Yes No Anaemia Yes No Chronic pain Site of pain Yes No ……………………………………………… Osteoporosis Yes No Chest pain on exertion Yes No Other PATIENT HISTORY FEV1 (Litres): FVC % predicted: FEV1/FVC ratio: BMI: Height (m) Weight (Kg) MUST Patient reported MRC dyspnoea score at assessment Grade 1 Grade 2 3 Grade 4 Grade 5 Not known Smoking status Never smoked Ex-smoker Current smoker since stopped? Pack How many a day? Home O2 at time of assessment NIV CPAP None Alcohol per week) Delivery of Oxygen Concentrator Cylinders Ambulatory Flow Rate Duration Vaccinations Influenza Yes/No/Declined/NK Pneumonia Yes/No/Declined/NK Date Date Hospital Days (last 12months) Exacerbations (last 12months)
Medication Date Dose Dose SABA Salbutamol (Ventolin) Terbutaline (Bricanyl) ACE INHIBITOR Enalapril Lisinopril Perindopril Ramipril Other SAMA LABA/LAMA Ipratropium (Atrovent) Duaklir Spiolto 340/12 BD 2.5/2.5 x2 OD ARB Candesartan Losartan Valsartan Olmesartan Other LABA Salmeterol (Serevent) Formeterol (Oxis) BETA BLOCKER Bisoprolol Carvedilol Atenolol Other LAMA Tiotropium (Spiriva) Aclidinium (Eklira) antianginals ISMN ISDN GTN Nicorandil ICS Flucticasone (Flixotide) Budesonide (Pulmicort) Becomethasone (qvar, clenil) DIURETICS Bumetanide Furosemide Bendro flumethazide Metolazone Thiazide Other ICS/LABA Seretide Symbicort Fostair Spiromax Spiromax 320/0 BD 160/4.5 BD aldosterone antagonist Eplerenone INHIBITOR Rofulmast (Daxas) Theophyline (uniphillin, Nuelin) Aminophylline ANTI- PLATELET/ Coagulant Aspirin Warfarin Clopidogrel Prasugrel Ticagrelor Other ORAL STEROIDS Prednisolone Digoxin Amiodarone Other MUCOLYTICS Sodium Chloride Carbocisteine Mecysteine CALCIUM CHANNEL BLOCKERS Amlodipine Felodipine Diltiazem Verapamil
ILD MEDICATION N-acetlcysteine Azathioprine Pirfenidone Nintedanib STATIN Atorvastatin Pravastatin Rosuvastatin Simvastatin Other Therapy for Lipids ……………….. ANTI-DEPRESSANTS/ ANXIOLYTICS Paroxetine Fluoxetine Citalopram Lorazepam Diazepam DIABETIC DRUGS Metformin Sulphonylurea Glimepiride Insulin Other current Diabetes Therapy ANTI-OSTEOPOROSIS Aledronic Acid (Fosamax) Risedronate (Actovel) Calcium preparation ANTIBIOTICS PPI / ANTI ULCER Esomeprazole Lansoprazole Omeprazole Ranitidine OTHER Continuation Date Signature