Pulmonary Rehabilitation
Referral Form
Date of referral:
Thank you for referring your patient to Pulmonary Rehabilitation provided by Suffolk Community
Healthcare.
Criteria for referral to Pulmonary Rehabilitation
The patient must have the following:
Confirmed diagnosis of COPD which is being
optimally treated
Patient Details
Name:
Address:
The following conditions will exclude someone from a
rehabilitation programme:
Severe musculoskeletal conditions
MI within last 6 weeks
Uncontrolled hypertension
Unstable angina
Acute LVF
Uncontrolled cardiac arrhythmias
Aortic stenosis
Uncontrolled diabetes
NHS no:
CRN no:
DOB:
Tel no:
Mobile no:
GP Details:
Relevant Medical History/co-morbidities:
Date spirometry performed:
FEV1:
FVC:
FEV1/FVC:
Current Medication (FP10 may be attached)
SpO2
on air
on LO 2
Oxygen therapy
No
LTOT
SBOT
AO
Exercise tolerance:
Additional information:
Person referring:
Contact details:
Signer/interpreter required (please specify):
Position:
Tel no:
Please return this form to: Suffolk Community Healthcare, Care Coordination Centre
Fax 01473 276470/1/2/3/4
We will contact the patient to arrange an assessment.
October 2013