Pulmonary Rehabilitation Intake Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Phone Number
Email Address
Address
Emergency Contact
Name
Relationship
Phone Number
Medical Information
Primary Respiratory Diagnosis
Other Medical Conditions
Current Medications
Allergies
Smoking History
Do you smoke?
Never
Current
Former
Packs per day
Years smoked
Functional Status
Do you have any physical limitations?
Do you use any assistive devices (cane, walker, oxygen, etc)?
Goals for Pulmonary Rehabilitation