PULMONARY REHABILITATION      PATIENT ID LABEL
                            Referral Form (Lungmax)                        Patients Name: <PtFullName>
              Respiratory Service: PO Box 547, Nambour       DOB: <PtDoB> 
                    Fax: 5370 3482          Tel: 5470 6768               Patient Conatact No: <PtPhoneH>   mob: <PtPhoneMob>
Address: <PtAddress>	
Please complete ALL sections
INCOMPLETE OR ILLEGIBLE FORMS WILL BE RETURNED	
REQUEST TO: LungMax Nambour     (Respiratory Physician)	
REQUESTING DOCTOR                                                                                <Practice>
Date of Request: <TodaysDate>                                                                    <UsrAddress>
Requesting Medical Officer: <DrName>                                                <UsrPhone>      <UsrFax>
Signature: ............................................................................ 
Provider No: <DrProviderNo>	
Diagnosis: <Diagnosis>
Problem List: <SelectedPMH> 	
Purpose of Referral: <Purpose of Referral>	
Lung Function: FEV1/ FVC: Spirometry attached             FEV1 (% of predicted) : Spirometry attached	
Relevant Past Medical History
<Cardiac Disease> Cardiac Disease (refer problem list)
<Peripheral Vascular Disease> Peripheral Vascular Disease (refer problem list)
<Diabetes Type 1 DM> Diabetes Type 1 DM                     <Type 2 DM> Type 2 DM                        <Hypertension> Hypertension  
Other (please specify) <Other (please specify)>	
Cardiac Medications (please list): <SelectedRx>	
Respiratory
<Beta Agonist> Beta Agonist          <ICS> ICS          <Oral Steriod> Oral Steriod          <LAMA> LAMA          <LABA> LABA          <Anti cholinergic> Anti cholinergic
Other (specify): <Other (specify)>
Oxygen / Flow rate: .......................................................      Hours per day: ...........................................	
Walking Aids / Mobility 
Specify Concerns: <Specify Walking Aids / Mobility>
Clients preferred Lungmax venue:    <Kawana Is. (all year)> Kawana Island <Gympie (all year)> Gympie  
                                                               <Noosa (all year)> Noosa  <Nambour (all year)> Nambour
Please consider the following when referring;
Absolute contraindications;    Unstable Angina in recent months, Recent Myocard event,  Critical Aortic                                                              Stenosis, and cognitive impairment not suited to group work.
Relative Contraindications:  Tachycardiac, arrhythmia, Severe hypertension systolic >180mmHG, Severe                                                                  Mobility problems, PVD with claudication.
Other considerations:  Review locomotor skills - spinal and joint disease may impede benefits of program.
                                       Withhold program for clients in an acute exacerbation (4-6wks post hosp. discharge)
                                       Clients with oxygen and stable medical conditions are eligible for consideration
                                       Must have ability or access to transport to nominated venue 2 times per week for 8                                                        weeks. Consider QHSP for assistance.