Tissue Gas Exchange Assessment
Please complete this assessment to help evaluate tissue gas exchange and related respiratory parameters.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Age
*
Contact Email Address
example@example.com
Presenting Symptoms (select all that apply)
*
Shortness of breath
Cyanosis (bluish discoloration)
Fatigue
Chest pain
Confusion
Other
Relevant Medical History
Chronic lung disease (COPD, asthma, etc.)
Heart disease
Smoking history
Recent surgery
None of the above
Objective Measurements
*
Rows
Value
Oxygen Saturation (%)
Respiratory Rate (breaths/min)
Heart Rate (beats/min)
Blood Pressure (mmHg)
Severity of Symptoms (Rate the following)
*
Rows
None
Mild
Moderate
Severe
Shortness of breath at rest
1
2
3
4
Shortness of breath with activity
5
6
7
8
Cyanosis
9
10
11
12
Chest pain
13
14
15
16
Fatigue
17
18
19
20
Physical Exam Findings
Normal breath sounds
Crackles/rales
Wheezing
Use of accessory muscles
Peripheral edema
Other
Overall Assessment of Tissue Gas Exchange
*
Impaired
1
2
3
4
Normal
5
1 is Impaired, 5 is Normal
Additional Comments or Observations
Submit Assessment
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