PULMONARY REHABILITATION     Respiratory Service: PO Box 547 Nambour:  
Referral Form (Lungmax):                                       Fax: 5370 3482          Tel: 5470 6768
Patients Name:   <<Patient Demographics:Full Name>>  
 Address: <<Patient Demographics:Full Address>>
DOB: <<Patient Demographics:DOB>>
Patient Contact No: <<Patient Demographics:Phone (Home)>>                                                                                       mob: <<Patient Demographics:Phone (Mobile)>>               	
Please complete ALL sections
INCOMPLETE OR ILLEGIBLE FORMS WILL BE RETURNED	
REQUEST TO: LungMax Nambour     (Respiratory Physician)	
REQUESTING DOCTOR                                                                
Date of Request:  <<Miscellaneous:Date>> 
Practice Name:    <<Practice:Name>>                    
Practice Address: <<Practice:Address>>                         
Requesting Medical Officer:          <<Doctor:Name>>      
Phone  <<Doctor:Phone>>     Fax; <<Doctor:Fax>>                                      
Signature: ............................................................................ 
Provider No: <<Doctor:Provider Number>>	
Diagnosis: <<Diagnosis>>
Problem List: <<Clinical Details:History List>>	
Purpose of Referral: <<Purpose of Referral>>	
Lung Function: FEV1/ FVC: Spirometry attached             FEV1 (% of predicted) : Spirometry attached	
Relevant Past Medical History: <<Clinical Details:History List>>
Cardiac Disease (refer problem list) <<Cardiac Disease>>
Peripheral Vascular Disease <<Peripheral Vascular Disease>> 
Diabetes Type 1. <<Diabetes Type 1.>>                    Diabetes Type 2. <<Diabetes Type 2.>> 
Hypertension <<Hypertension>> 
Other please specify <<Other- please specify>> 	
Medications: <<Clinical Details:Medication List>>	
Respiratory Medications
Beta Agonist <<Respiratory Medications:       Beta Agonist>>   
ICS <<ICS>>                            Oral Steroids <<Oral Steroid>>                          LAMA       <<LAMA>> 
LABA <<LABA>>                     Anti cholinergic <<Anti cholinergic>>                 Other: (please specify) <<Other - please specify>>  
Oxygen/ Flow Rate <<Oxygen / Flow Rate>>:    Hours per day:  <<Hours per day; >>	
Walking Aids / Mobility 
Specify Concerns: <<specify walking aids/mobility concerns>>
Clients preferred Lungmax venue:    <<Clients preferred Lungmax venue:>>
                                                        
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.