• Atelectasis Diagnostic Evaluation Form

    Use this form to document symptoms, risk factors, examination findings, imaging results, and clinical assessment for possible atelectasis.

  • Patient and Visit Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex at Birth / Gender
  • Date of Evaluation*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Respiratory Symptoms and History

  • Shortness of breath*
  • Cough type
  • Chest pain*
  • Fever or chills*
  • Worsening factors or triggers
  • Previous similar episodes or known lung conditions

  • Risk Factors and Relevant Medical History

  • Recent surgery?*
  • Date of recent surgery
     - -
    2 digit month, 2 digit day, 4 digit year
  • Recent anesthesia or sedation?
  • Prolonged bed rest or immobility?
  • History of chronic lung disease
  • Known aspiration risk or neuromuscular weakness?

  • Physical Examination Findings

  • Lung Auscultation Findings
  • Use of Accessory Muscles
  • Reduced Chest Expansion

  • Diagnostic Tests and Imaging

  • Chest X-ray status*
  • CT scan status
  • Arterial blood gas or other lab results
  • Bronchoscopy status

  • Severity Assessment and Clinical Impression

  •
  • Extent of Suspected Atelectasis
  • Suspected Laterality
  • Likely Contributing Factor(s)

  • Plan and Follow-Up

  • Oxygen therapy recommended?*
  • Incentive spirometry or breathing exercises recommended?*
  • Pulmonary hygiene measures
  • Need for referral or escalation?*
  • Follow-up date or timeframe
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty:
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