Physiotherapy

Respiratory Assessment
Form

Name: DOB:
NHS Number: Home:
Staff name: Staff Signature: Date:
Subjective

PC:

HPC:

PMH:

DH:

FH:

SH:

Relevant investigations / Current Treatment Plan:

1
 Physiotherapy Respiratory Assessment Form

Name: DOB:
NHS Number: Home:
Staff name: Staff Signature: Date:
Observation and Initial Presentation

Swallowing:

-Effective:

-Retaining food/secretions:

-Aspirates:

Other notes:

2
 Cough:
Onset: Sudden ☐ Gradual ☐

Duration: Acute ☐ Persistent ☐ Chronic ☐

Nature: Dry irritation ☐

Wet signs of Infection ☐

Productive: Yes ☐ No
☐

Comments:

Physiotherapy Respiratory Assessment Form

Name: DOB: NHS Number: Home:

Staff name: Staff Signature: Date:

Sputum:
Amount (ml): Colour: Viscosity:

Details…………………………………………………….

Breathlessness – related to level of function:

Exercise tolerance: ☐ Grade 1 ☐ Grade 2

☐ Grade 3 ☐ Grade 4

Associated swelling of ankles: ☐ Yes ☐ No

Sudden or constant: ☐ Sudden

☐ Constant

Chest pain: Yes ☐ No ☐

Skin Colour:

Finger Clubbing: Yes ☐ No ☐

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 Physiotherapy Respiratory Assessment Form

Name: DOB:
NHS Number: Home:
Staff name: Staff Signature: Date:

Body Chart

4
 General appearance, posture and observation of chest:

Auscultation and added sounds:

Physiotherapy Respiratory Assessment Form

Name: DOB:
NHS Number: Home:
Staff name: Staff Signature: Date:

Vital signs:
Temperature: Blood pressure:

Pulse: SpO2:

Respiration rate:

Breathing pattern:

5
 Other Outcome Measures used:

Mobility:

Transfers:

Physiotherapy Respiratory Assessment Form

Name: DOB:
NHS Number: Home:
Staff name: Staff Signature: Date:

Summary of impairments:

6
Clinical impression:

Expectations of Treatment from Service User:

Treatment Plan: