Referral for Pulmonary Rehabilitation Program
Name
Phone Number
Is client aware of referral?
Yes 
Address
No 
Has client agreed to attend?
Yes 
No 
Primary Diagnosis:
Has diagnosis been confirmed with spirometry? Yes 
No  (if no please arrange spirometry)
Eligibility:
Other Significant Medical History:
□ Client has stable or other respiratory disease
□ No severe cognitive impairment
□ No severe psychotic disturbance
□ No infectious diseases
Other Significant Issues: (Pacemaker, allergies, oxygen use,
mobility aids etc.)
Current Medications
dosage,
frequency
Does client have any of the following that may affect ability to
participate in activities?
□ Musculoskeletal / neurological disorders preventing gentle
exercise.
□ Unstable cardiovascular disease
□ Metastatic Cancer
This is to certify that the above patient is medically fit to attend and participate in the Pulmonary Rehabilitation Program.
By signing this form you are consenting to your patient undertaking pulmonary rehabilitation, including pre and post attendance
6 minute walk test. If pre 6mwt indicates hypoxia you will be informed and patient will need formal home oxygen assessment
prior to being accepted on a rehabilitation course
Name:
Designation:
Provider No:
Signature:
Address:
Date
Medical Clearance Form (To be completed and signed by a doctor):
Please return signed forms to : Pulmonary Rehabilitation Coordinator, Respiratory CNC: Royal Darwin Hospital
Phone: 08 89448059
Fax: 08 89228111
email respiratorycnc.ths@nt.gov.au
The Pulmonary Rehabilitation Toolkit: An Initiative of The Australian Lung Foundation and Australian
Physiotherapy Association