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Demographics
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Patient
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Account#
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DOB
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Visit Date/Time
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Diagnosis
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Physician/Clinic
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Gender
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Race
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Ethnicity
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Physical Assesment
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Height (patient reported)
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Weight (patient reported)
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Allergies
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Color
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Circulation
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Pain Assessment
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Headaches
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Cough
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Breath Sounds
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Lung Field
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Sputum
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Sputum Color
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Respiratory Vitals
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Dyspnea (using Borg Scale)
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Spirometry FEV1
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GOLD Stage
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SpO2
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Pulse Oximetry on
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PulseOx LPM
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Heart Rate
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RT Comments/Follow-Up Plan
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Comments
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CAT Score
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Cough
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Phlegm
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Chest Tightness
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Walk Up Hill or Stairs
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Activities at Home
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Leaving the House
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Sleep
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Energy
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CAT total score
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Physician/Specialist Care
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Who usually takes care of your COPD?
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How often do you see your pulmonologist?
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How often do you see your PCP?
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Hospital or ER in last 12 months for COPD?
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If yes, how many times & explain
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Medication/Therapy
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Do you use oxygen?
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Oxygen LPM
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Oxygen frequency
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Last flu shot?
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Please explain why
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Had pneumonia shot?
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Date of initial pneumonia shot
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Date of booster pneumonia shot
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COPD Exacerbations
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What makes your COPD worse?
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Other COPD triggers
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How have you dealt with panic over SOB?
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Nutrition (* possible RD intervention triggers)
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How would you describe your weight?
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Have you lost more than 10 lbs in last 6 months?
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Talk to your doctor about sudden weight changes?
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What diet are you following?
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Other diet
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Who is responsible for your daily meals?
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Other meal preparer
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How many meals do you eat per day?
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How many glasses of fluid do you drink per day?
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Did your doctor tell you to limit fluids?
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Change in appetite in past 6 months?
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Experience any of the following when eating? *
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Any chewing/swallowing difficulties?
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Lost your ability to taste food?
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Fitness/Well-being
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Physical activity limited by any condition?
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Do you have any type of exercise routine?
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Exercise routines
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Other fitness routine
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Smoking/Tobacco Use
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Have you ever smoked on a regular basis?
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Number of packs per day
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Number of years smoked
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Enter pack years
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Quit date
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Do you currently use tobacco products?
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What tobacco products do you use?
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Have you tried quitting in the past?
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Are you interested in quitting?
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Home Environment Assessment
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Access to home, stairs, ramp, handrails, etc.
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Required action(s) on Home Access
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Width of entrance door
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Required action(s) on Door Width
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Internal doors and hallways wide enough
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Required action(s) on Internal Doors/Hallways
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Telephone service and accessibility
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Required action(s) on Telephone Accessibility
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Adequate heat/air conditioning
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Required action(s) on Heat/Air Conditioning
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Space requirements for equipment and supplies
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Required action(s) on Equipment Space
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Adequate work, cleaning, storage space
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Required action(s) on Storage Space
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Proximity of primary, secondary caregiver(s)
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Required action(s) on Caregiver Proximity
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Cleanliness and general condition of home
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Required action(s) on Home Cleanliness
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Therapy Learning Assessment
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Patient able to understand therapy, equipment
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Required action(s) on Patient Understanding
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Caregiver support and able to understand
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Required action(s) on Caregiver Understanding
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Patient understands pulseox, PCF, how to respond
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Required action(s) on Patient Response
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Comments/Follow-Up Plan
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