Get the free Pulmonary Rehabilitation Referral Form

This document is a referral form for patients seeking pulmonary rehabilitation and respiratory services at the Vanderbilt Rehabilitation Center at Newport Hospital. It includes sections for patient information, insurance details, diagnosis, required testing, and physician consent.

How to fill out pulmonary rehabilitation referral form

How to fill out pulmonary rehabilitation referral form

1. Begin with the patient's personal information: full name, date of birth, and contact details.
2. Fill in the medical history section with relevant diagnoses, previous treatments, and current medications.
3. Include the patient's smoking history, indicating whether they are a current smoker, former smoker, or non-smoker.
4. Document the patient's respiratory symptoms such as shortness of breath, cough, and sputum production.
5. Indicate any functional limitations the patient experiences due to respiratory conditions.
6. Specify any pulmonary function tests or imaging studies conducted, along with their results.
7. Provide the referring physician’s information, including name, specialty, and contact details.
8. Add any additional notes or comments that could assist with the rehabilitation process.
9. Review the completed form for accuracy and completeness before submission.

Who needs pulmonary rehabilitation referral form?

1. Patients with chronic respiratory conditions such as COPD, asthma, or pulmonary fibrosis.
2. Individuals recovering from lung surgeries or hospitalizations due to respiratory issues.
3. Patients with reduced physical activity levels due to breathing difficulties.
4. Individuals with a history of smoking who have chronic lung damage.
5. Patients requiring support in managing their respiratory symptoms and improving their quality of life.

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What is pulmonary rehabilitation referral form?

The pulmonary rehabilitation referral form is a document used by healthcare providers to refer patients with chronic respiratory diseases to a pulmonary rehabilitation program, which aims to improve patients' quality of life through education, exercise, and support.

Who is required to file pulmonary rehabilitation referral form?

Healthcare providers such as physicians, nurse practitioners, or physician assistants are typically required to file the pulmonary rehabilitation referral form for patients who meet the criteria for pulmonary rehabilitation.

How to fill out pulmonary rehabilitation referral form?

The pulmonary rehabilitation referral form should be filled out by providing the patient's demographic information, medical history, current medications, pulmonary function test results, and any specific recommendations for therapy, ensuring all required fields are completed.

What is the purpose of pulmonary rehabilitation referral form?

The purpose of the pulmonary rehabilitation referral form is to initiate the referral process for patients to receive specialized care that includes exercise, education, and support to manage their chronic lung conditions effectively.

What information must be reported on pulmonary rehabilitation referral form?

The referral form must include patient identification details, diagnosis, smoking history, assessment of symptoms, recent clinical evaluations, and any previous treatments or therapies undertaken.