BARCODE 1111
PULMONARY REHABILITATION PROGRAM
Department of Respiratory & Sleep Medicine
John Hunter Hospital, Lookout Road,
New Lambton Heights Postal: Locked Bag 1,
Hunter Region Mail Centre, Newcastle 2310
Telephone: 4921 3470 Facsimile: 4921 3469
SURNAME
UNIT NUMBER
OTHER NAMES
ADDRESS
DATE OF BIRTH
___/___/___
Dear Dr ______________________________
Mr / Mrs / Ms ______________________________ has been assessed to do Pulmonary
Rehabilitation at the John Hunter Hospital. The aim of this programme is to improve exercise
tolerance, confidence, quality of life, and to increase patient knowledge of COPD and its
management. Please find below a summary of our Initial Assessment. You will find outcome
measures for Pulmonary Function, Health status questionnaire, Six Minute Walk Testing,
Prognostic Indicators, Self Management skills, and relevant Clinical data.
Baseline
Date
Pulmonary Function
FEV1 (% Predicted)
FVC (% Predicted)
FEV1/VC%
Health status
CAT¥
Six Minute Walk Test
6 MWT distance
Prognostic Indicators
BODE
Self Management skills
Inhaler technique
Adherence
Exacerbations
Clinical data
Weight and BMI
HADS€
Your patient will commence Pulmonary Rehabilitation on _________________________
Our service will provide pre and post outcomes when the programme has been completed.
……………………………………………………………………………………………………..…...
………………………………………………………………………………………………………….
Kind regards
Respiratory Liaison Nurse
Copy To: Patient, Respiratory Consultant, Vanessa McDonald
Page 1 of 2
Hunter New England Health Service
ABN 24 500 842 605
www.hnehealth.nsw.gov.au
BARCODE 1111
PULMONARY REHABILITATION PROGRAM
Department of Respiratory & Sleep Medicine
John Hunter Hospital, Lookout Road,
New Lambton Heights Postal: Locked Bag 1,
Hunter Region Mail Centre, Newcastle 2310
Telephone: 4921 3470 Facsimile: 4921 3469
SURNAME
UNIT NUMBER
OTHER NAMES
ADDRESS
DATE OF BIRTH
Description of Outcome Measures
Modified Medical Research Council Dyspnoea Scale (MMRC)*
*Health Status Questionnaire
The health status measurement used is the St George
Respiratory Questionnaire (SGRQ). The SGRQ is a
standardized self-completed questionnaire for measuring
impaired health and perceived well-being ('quality of life') in
airways disease. It has been designed to allow comparative
measurements of health between patient populations and
quantify changes in health following therapy. The questionnaire
covers aspects of disability in patients with chronic lung
disease in terms of dyspnoea, fatigue, emotional function and
master.
Grade
“I only get breathless with strenuous exercise”
“I get short of breath when hurrying on the level or walking
up a slight hill”
2
“I walk slower than people of the same age on the level
because of breathlessness, or have to stop for a breath
when walking at my own pace on the level”
3
“I stop for a breath after walking about 100 yards or after a
few minutes on the level”
4
“I am too breathless to leave the house, or I am breathless
when dressing”
NB: This is the modified MRC scale that uses the same
descriptors as the original MRC scale in which the descriptors are
numbered 1-5. The modified MRC scale (0-4) is used for
calculation of BODE index.
0
1
A higher score indicates greater impairment. A change in
score of 4 units is clinically.
The St George's Respiratory Questionnaire. Jones PW, Quirk FH, Baveystock
CM. Respir Med. 1991 Sep;85 Suppl B:25-31;
¥The COPD Assessment Test (CAT) is a new quality of life
€HADS Hospital Anxiety and
Depression Scale
Is a screening tool used in many clinical settings to screen for
anxiety and depression. Any score in either domain equal to or
greater than 8 indicates possible anxiety or depression.
tool for people with COPD. It is a survey with eight simple
questions which only takes a few minutes to complete. This is
a patient centred questionnaire to assist health professionals
understand more clearly and quickly the patients experience
of COPD. Jones etal in The Eur Respir J 2009; 34: 648-654
Available online www.catestonline.org
Borg
GA Borg Medicine and Science in Sports and
BODE: Variables and Point Values Used for the
Computation of the Body. Mass Index, Degree of Airflow
Obstruction and Dyspnea, and Exercise Capacity (BODE)
Index. 
Exercise, Volume 14, 1982
Modified Borg Dyspnoea Scale
0
0.5
1
2
3
4
5
6
7
8
9
10
Zigmond A. S. Snaith RD The Hospital anxiety and
depression scale. Acta. Psychiatr Scand 1988; 67:361-370
Nothing at all
Very, very slight (just noticeable)
Very slight
Slight
Moderate
Somewhat severe
Severe

The cut off values for the assignment of points are shown for each
variable. The total possible values range from 0 to 10. FEV1 denotes
forced expiratory volume in one second.
 The FEV1 categories are based on stages identified by the American
Thoracic Society.
 Scores on the modified Medical Research Council (MMRC) dyspnea
scale can range from 0-4, with a score of 4 indicating that the patient is
too breathless to leave the house or becomes breathless when dressing
or undressing.
 The values for body-mass index were 0 or 1 because of the inflection
point in the inverse relation between survival and body-mass index at a
value of 21. N ENGL JMED 350:10 www.NEJM.ORG MARCH4, 2004
Very severe
Very, very severe (almost maximal)
Maximal
Variable
BODE Index
Patient Instructions for Borg Dyspnoea Scale
“This is a scale that asks you to rate the difficulty
of your breathing. It starts at number 0 where your
breathing is causing you no difficulty at all and
progresses through to number 10 where your
breathing difficulty is maximal. How much difficulty
is your breathing causing you right now?”
Page 2 of 2
FEV1 (% of predicted)

Distance walked in 6
min (m)
MMRC dyspnea scale

Body-mass index 
Points on
0
>65
1
50-64
2
36-49
>350
250-349 150-249 <149
0-1
2
>21
<21
3
3
<35
4
Hunter New England Health Service
ABN 24 500 842 605
www.hnehealth.nsw.gov.au