Referral to County Durham Darlington Nhs Ft

REFERRAL TO COUNTY DURHAM DARLINGTON NHS FT

FOR PULMONARY REHABILITATION

Name: / NHS Number:
Address:
Telephone Number:
Date of Birth: / Consultant:
GP Name:
GP Address:
GP Telephone Number:
Respiratory Diagnosis:
Medical history: Is this patient cardiovascularly stable? Yes / No
Previous M I / cardiac surgery If yes, specify below Y / N / Epilepsy Y / N
Joint or bone disease Y / N
restricting function / Vertigo or other Y / N
Dizziness related symptoms
Ischaemic heart disease Y / N / Diabetic Y / N
If yes, specify below
Previous falls or at risk of falls Y / N / Hypertension Y / N
Previous stroke Y / N
Other relevant medical history:

Medication

Usual Inhaled Therapy

Name / Drug / Dose / Route/device
Short acting beta II agonist
Anti-cholinergic
Inhaled Corticosteroid(LABA combination)
Long acting Beta II agonist
Nebulised therapy

Tablets & Non- Inhaled Therapy (please attach computer printout if appropriate)

Recent Spirometry Results and Date Taken:

Date / Value (Litres) / % Predicted
FEV1
FVC
FEV1/FVC ratio
PEF
MRC score / BMI / Exercise Tolerance

Name of Referrer: Referrer Signature:

Designation: Date:

Please attach this to a Choose and Book referral

Or return by fax/post to

Physiotherapy Dept, Darlington Memorial Hospital - for referrals for Darlington, Bishop Auckland, Sedgefield, Richardson Hospital (Fax - 01325 743855)

Or, to AHP team at Merrington House for referrals for Durham, Chester-le-Street and Shotley Bridge (Fax – 01388 825701)

Inclusion Criteria

· Agree to attend full programme bi-weekly for eight weeks

· Confirmed respiratory diagnosis

· Therapy optimised

· County Durham or Darlington registered GP

Exclusion Criteria

· Cognitive impairment that restricts compliance to group activities

· Loco motor disability that would inhibit exercise

· Unstable angina/cardiac disease

· MI in past six weeks