Pulmonary Rehabilitation Assessment Protocol:

NHS Board Area: ____________________________________________________

Name: _____________________________________________________________

CHI number: ________________________________________________________

Date of assessment: ______________________ Time: _______________________

Location of assessment: _______________________________________________

Class start date/time: __________________________________________________

Re-Assessment Date/Time: _____________________________________________

Transport Requirements: ______________________________________________

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 MEDICAL HISTORY

Diagnosis: ________________________________________________________________________
Date of diagnosis: __________________________________________________________________
Symptoms:________________________________________________________________________
_________________________________________________________________________________
Date of most recent exacerbation: _____________________________________________________
Was patient admitted to hospital: Yes/No Length of stay:________________________

Co-morbidities:
Angina: Yes/no Type I diabetes: Yes/no
Heart Failure: Yes/no Type II diabetes: Yes/no
Epilepsy: Yes/no Cochlear implant: Yes/no
Pacemaker: Yes/no
Other (please specify):

Medication: Inhaler Nebules Medication

Beta 2 Agonist □ □
Long-acting Beta 2 Agonist □ □
Anticholingergic □ □
Long acting anticholingergic □ □
Beta 2 Agonist & anticholinergic □ □
Corticosteroid □ □
Combined Beta 2 Agonist & corticosteroid □ □
Corticosteroid & long acting beta 2 agonist □ □
Oxygen cylinder □ LTOT □ L/min.____

Prednisolone (acute) □ Date commenced:____________________________

Prednisolone (acute) □
MEDICAL HISTORY (CONTINUED)

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 Respiratory: Other:

Reminder Given Regarding: Flu Vaccine □ (yearly) Pneumonia Vaccine □

Weight:__________ Kg Height: __________ M BMI: __________
History of recent weight loss? Yes/No ____________________

DEVICE TECHNIQUE:___________ Inhaler technique checked: Yes □ No □

Problems/Action:___________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature:______________________________________________________

Reassesment:______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature:______________________________________________________

Home Circumstances:

Living with spouse/carer □______________________________________________

Living alone with support □______________________________________________
Living alone without support □______________________________________________
Residential Home □______________________________________________
OT adaptations/equipments □______________________________________________

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Glasgow & Clyde
 ACTIVITY PROFILE

The MRC dyspnoea scale:

□ Grade 1 “I only get breathless with strenuous exercise”

□ Grade 2 “I get short of breath when hurrying up on the level or up a slight hill”
□ Grade 3 “Ibreathlessness
walk slower than people of the same age on the level because of
or having to stop for breath when walking at my own pace on
the level”

□ Grade 4 “I stop for breath after walking 100 yards or after a few minutes on the level”
□ Grade 5 “I am too breathless to leave the house”
Comments:

Stairs: Yes/No Internal □ External □ Chair lift □

Current services:

Home Help □ Meals on wheels □ Social worker □

District Nurse □ Respiratory Liaison Nurse □ OT □
Other □ ______________________________________________

Comments:

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Glasgow & Clyde
 SMOKING HISTORY

Current smoker □ Cigarettes □ Cigars □ Pipe □

Ex-smoker □ If ex-smoker, how long: __________________________

Never smoked □
No. of Pack Years: ________ per day/________ years =
Wants to stop smoking? Yes/No
Would you like to stop in the next two weeks? Yes/No

Stage of behavioural change at assessment:

Pre-contemplation □ Relapse □
Contemplation □ Maintenance □
Action □
Stage of behavioural change at reassessment:

Pre-contemplation □ Relapse □
Contemplation □ Maintenance □
Action □
1. Have you felt depressed or worried over the last few months/weeks? Yes/No
2. In the past have you ever had any problems related to worry/depression? Yes/No
3. Have you experienced any major life events or losses in the last year? Yes/No
4. Have you stopped doing anything in the last year?_____________________________________ Yes/No

Comments:

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Glasgow & Clyde
INCREMENTAL SHUTTLE WALKING TEST

DATE:

SHUTTLES Level SaO2 Heart rate

0 Rest
1 2 3 1
4 5 6 7 2
8 9 10 11 12 3
13 14 15 16 17 18 4
19 20 21 22 23 24 25 5
26 27 28 29 30 31 32 33 6
34 35 36 37 38 39 40 41 42 7
43 44 45 46 47 48 49 50 51 52 8
53 54 55 56 57 58 59 60 61 62 63 9
64 65 66 67 68 69 70 71 72 73 74 75 10
76 77 78 79 80 81 82 83 84 85 86 87 88 11
89 90 91 92 93 94 95 96 97 98 99 100 101 102 12

Oxygen No □ Yes □ ___________ L/min Lowest SaO2 recorded: ___________

Distance walked: _________ metres Borg score: Pre-test_________ Post-test:_________
Test stopped due to:____________________

Comments:

Signature:________________________________

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provided by the Pulmonary Rehabilitation service within NHS Greater
Glasgow & Clyde
 ENDURANCE WALKING TEST

LEVEL:
ASSESSMENT DATE: REASSESSMENT DATE:
Time SaO2 HR Comments Time SaO2 HR Comments
Resting Resting
0 min. 0 min.
2 min. 2 min.
4 min. 4 min.
6 min. 6 min.
8 min. 8 min.
10 min. 10 min.
12 min. 12 min.
14 min. 14 min.
16 min. 16 min.
18 min. 18 min.
20 min. 20 min.

MAXIMUM ENDURANCE TIME:

Assessment:………. mins……….. secs………… Ressessment:……. mins………. secs…………

Borg score – Pre test: ……….. Post-test……….. Borg score – Pre test: ……….. Post-test………..
Test stopped due to……………………………….. Test stopped due to………………………………..
Lowest SaO2 recorded ______________% Lowest SaO2 recorded ______________%

Comments: Comments:

Signature:…………………………………………… Signature:……………………………………………

QUALITY OF LIFE QUESTIONNAIRES

Pre Post
Dyspnoea
Fatigue
CRQ-SR
Emotional Function
Mastery
Anxiety
HAD
Depression
PATIENT GOALS:

DISCUSSION OF PATIENT GOALS AT RE-ASSESSMENT

Signature:………………………………………….. Signature:………………………………………………..

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provided by the Pulmonary Rehabilitation service within NHS Greater
Glasgow & Clyde
Date Clinical notes Signature

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provided by the Pulmonary Rehabilitation service within NHS Greater
Glasgow & Clyde
Date Clinical notes Signature

Date Referrals/Self referral Location

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provided by the Pulmonary Rehabilitation service within NHS Greater
Glasgow & Clyde