Pulmonary Rehabilitation Progress Form
Patient Name
Date of Assessment
Medical Record Number
Diagnosis
Program Start Date
Program Session Number
Current Symptoms (e.g., dyspnea, cough)
O2 Saturation (Rest)
O2 Saturation (Exercise)
Heart Rate
Borg Dyspnea Scale
Borg Fatigue Scale
Blood Pressure
Exercise Training (type, duration, intensity)
Education Topics Covered
Adverse Events / Complications
Progress Notes
Clinician Name
Signature
Date