Bronchiectasis Physiotherapy Assessment Form (Patient label)

Assessment date:_____________________________ Medical record no:_________________

Name:______________________________________DOB:___________________________

Address:____________________________________________________________________

Ph:_______________________________________ Mob:____________________________

Referred by:________________________________________________________________

GP:________________________________________________________________________

Approx. date of diagnosis:_______________________________________________________

Approx. date when started symptoms:______________________________________________

Past history (respiratory):________________________________________________________

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Co-morbiditites:_______________________________________________________________

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Cardiac history:_______________________________________________________________

© 2018 Last reviewed May 2018

Lung surgery: Yes / No Date:_____________ Operation:_____________________________

Musculoskeletal pain: Y / N Location:_______________________________________

Severity (rating out of 10/VAS)___________________________________________________

Impact on physiotherapy treatment:________________________________________________

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Smoker: Y / N Pack years:_____________ Year stopped smoking:_______________

Daily cough: Y / N Irritable / productive_________________________________________

Sputum quantity:_______________________ Colour:__________________________________

Haemoptysis:___________________________________________________________________

Ease of expectoration:____________________________________________________________

Sleep (affected by cough?):________________________________________________________

Infections over past 12 months: Nil ≤2 ≥3 ≥5 _________________

GOR: Yes / No Treatment:____________________________________________

Sinusitis: Yes / No Treatment:____________________________________________

HRCT:________________________________________________________________________

LFT’s:_________________________________________________________________________

Auscultation:____________________________________________________________________

© 2018 Last reviewed May 2018

SpO2:____________________________ HR:________________________________

Respiratory medications: __________________________________________________________

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Other medications:_______________________________________________________________

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Oxygen therapy: Yes / No Portable / Continuous Flow rate:____________________

Urinary incontinence: Yes / No Treatment:__________________________________________

Hydration (per cup): Water____ Coffee_____ Tea______ Alcohol_____ Other_______________

Owns a nebuliser? Yes / No Type:___________________________________________

Current AC routine:_______________________________________________________________

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Past physio treatment:_____________________________________________________________

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Gait aids: Yes / No Type: __________________________________________________________

© 2018 Last reviewed May 2018

Current exercise:___________________________________________________________________

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Exercise limitations:________________________________________________________________

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Comments:_______________________________________________________________________

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Treatment plan:___________________________________________________________________

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Letter sent to referrer: Yes / No

Assessed by:____________________________________________________________________

Review appointment:______________________________________________________________

© 2018 Last reviewed May 2018