[PLEASE REVIEW AND UPDATE AS APPROPRIATE TO YOUR SERVICE] Pulmonary Rehabilitation Patient Record Patient ID or Patient name: ……………….………. Consultant/Therapist: DOB: .……….…………………….……… Male/Female: ……………….……… Consent form signed NHS number:…..…………….………. Medication recorded Questionnaires returned PATIENT DETAILS GP Name and Patient Address: address: Postcode: GP Postcode: Telephone (day): GP telephone Mobile: Next of Kin NoK telephone Interpreter Relationship to YES NO required? patient Languages English Welsh Hindi Bengali Urdu Punjabi Gujarati spoken Other: White British □ Pakistani □ White Irish □ Bangladeshi □ Any other White background □ White and Asian □ Caribbean □ Any other Asian background □ African Ethnicity: □ Chinese □ White and Black Caribbean □ Any other ethnic group □ White and Black African □ Any mixed background □ Any other Black background □ Not stated □ Indian □ Access to internet at home and confident using Web access and Access to internet at elsewhere and confident using web literacy Access to internet with assistance No access/not web literate Housing House / Flat / Bungalow Full-time Part-time Stairs YES NO Employment status Unemployed Retired Other: Stair Lift YES NO Lives alone Occupation Lives with spouse/partner Social Age when left Circumstances with family education? YES NO Requires Patient is a carer? YES NO Transport? YES NO Pt dependent on carer? Risk Factor: Yes / No MRSA: Site: Sputum Wound Flaking Skin Previous MRSA Contact: Yes / No +ve -ve (if answer is yes to any question then please fill in MRSA screening tool)
[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)
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