MVD MVR Cardiac AVD AVR Arrest Congenital Heart Pulmonary Hypertension angina Angina Atrial Fibrillation Heart Failure CHD stenosis Severity……………….. Severity……………… Neurological Parkinsons Epilepsy Infectious HIV Hepatitis Diseases Catarrhalis) Diverticulitis Crohns Disease GI Hernia Ulcerative colitis Cancers Yes No Please specify:……………………… Depression Psychiatric disorder Dementia/Alzheimer’s Falls in last Yes No If Yes, how many? ………………………… year Cognitive Yes No Anaemia Yes No impairment Chronic pain Yes No Yes No Osteoporosis Site of pain ……………………………………………… Chest pain on Yes No exertion Other PATIENT HISTORY FEV1 (Litres): FVC % predicted: FEV1/FVC ratio: BMI: Height (m) Weight (Kg) Patient reported Grade 1 Grade 2 3 MUST MRC dyspnoea Grade 4 Grade 5 Not known score at assessment Never smoked Ex-smoker Smoking status since stopped? Current smoker Pack How many a day? Home O2 NIV CPAP None Alcohol per week) at time of assessment Flow Rate Delivery of Concentrator Cylinders Oxygen Ambulatory Duration Influenza Yes/No/Declined/NK Date Vaccinations Pneumonia Yes/No/Declined/NK Date Hospital Days Exacerbations (last 12months) (last 12months)
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)
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