Criteria for Pulmonary Rehabilitation programme
1.
2.
3.
4.
Patient perceives themself as functionally disabled by COPD or similar chronic lung
condition (ie. their breathlessness is limiting their ability to do what they want to do in
their daily life).
Able to walk at least 10 metres.
No unstable angina.
No neurological, musculoskeletal or psychological impairment to exercise.
Pulmonary Rehabilitation referral form
……………………………………………………
…………………………………………………………………………..
…………………………………………………………………………..
Tel no.
……………………………
DOB
……………
GP/Surgery …………………………………………………………………….
Name
Address
Diagnosis
………………………………………………………………………..
Previous medical history (or attach practice
summary)………………………………………………………………………………………………
…………………………………………………………………………………………………………
………………………………………………………….
FEV1
FVC
FEV1/FVC
…………litres ( ……..% predicted)
………....litres ( ……..%predicted)
………...%
MRC Score (1-5)
…………
Does the patient use oxygen therapy?
Resting Blood Pressure
Resting Heart Rate
Yes/ No
………………..
………………..
Does the patient suffer from chest pain?
Yes/ No
If yes, please answer the following 2 questions:
Has this chest pain been medically assessed?
Yes/ No
Cause of chest pain ……………………………………………………………
……………………………………………………………………………………
Referrers Name and designation (print) …………………………………………………..
Referrers address (print) ……………………………………………………………………..
Referrers signature
………………………………
Date of referral
…………..............
Please send to: Louise Goswell, Respiratory Specialist Physiotherapist, Community Respiratory Team,
Brookfields Hospital, 351 Mill Rd, Cambridge, CB1 3DQ. Tel: (01223) 723013, Fax: (01223) 723002