Pulmonary Rehabilitation Referral Form
Date of referral……………………………………..Hosp No………………………………
Patient’s Name……………………………………..D.o.B. ………………………………..
Address: ……………………………………………………………………………………
……………………………………………… ……Contact No. ………………………….
G.P. Name & Address: ………………………………………………………………...........
……………………………………………………. Tel. No: ………………………………
Respiratory Diagnosis………………………………………………………………………
Home 02:
No
Smoking History
Yes
S
MRC Dyspnoea Score (please circle) 1/ 2/ 3/ 4/ 5
Ex-
Past Medical History (or attached printout)
N
Medications (or attached printout)
Exercise Tolerance…………………………………………………………………………
Spirometry: Date of test (within 1 year or 6 months if severe or recent deterioration)
FEV1 : ……….. %
If COPD- Gold Classification:
FVC ………….%
MOD
FEV1/FVC …………...%
SEVERE
Referrer Name:…………………………………………………………………....................
Designation…………………………………………………………………………………..
Contact details if different to GP details……………………………………………………..
……………………………………………………………………………………………….
Signature…………………………………………………………………………………….
Please phone if you need to discuss any patient referral on 020 8725 3016
Please fax BOTH sheets to Respiratory Liaison Physiotherapy on 020 8725 2432
Referral Criteria: (please tick to confirm)
Inclusion Criteria: Pulmonary rehab may be appropriate if the patient has:
* Recent admission to hospital and MRC 2
* Confirmed Respiratory Diagnosis
* Agreeable to being referred and can commit to attending twice a week for approx 7 weeks
*
* No cardiac event in last 6 weeks
*Any known cardiac condition (e.g. angina) must be well controlled and stable
Exclusion Criteria: Pulmonary Rehab is NOT appropriate is the patient has significant
co-morbidities that render them unable or unsafe to exercise:
* Severe/uncontrolled Heart Failure
* Unstable angina
* Uncontrolled hypertension
* Uncontrolled cardiac arrhythmias
* Inability to walk 10metres independently (with or without aids)- please refer to respiratory
community physiotherapy
* Inability to follow simple commands (in a group environment)
* Eye/abdominal surgery performed within 3 months
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MRC Dyspnoea Scale
1) I only get breathless with strenuous exercise
2) I only get short of breath when hurrying on the level or walking uphill
3) I walk slower than people of the same age on the level because of my breathlessness or have to stop
for breath when walking at my own pace on the level
4) I stop for breath after walking 100 yards or after a few minutes on the level
5) I am too breathless to leave the house, or am breathless on dressing or undressing
Please fax BOTH sheets to Respiratory Liaison Physiotherapy on 020 8725 2432