Respiratory Care Rehabilitation Assessment Form
Use this form to assess respiratory symptoms, functional limitations, and rehabilitation needs.
Patient and Assessment Overview
Patient Name
*
First Name
Middle Name
Last Name
Age
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Clinician or Department
Primary Respiratory Diagnosis or Reason for Rehab Assessment
*
Please Select
COPD
Asthma
Interstitial Lung Disease
Bronchiectasis
Post-COVID Respiratory Symptoms
Post-Surgical Respiratory Recovery
Neuromuscular Respiratory Weakness
Other
Respiratory Status and Symptom Assessment
Current respiratory support
*
Room air
Supplemental oxygen
Ventilator support
Non-invasive ventilation
Other
Symptom severity
*
Rows
None
Mild
Moderate
Severe
Shortness of breath
1
2
3
4
Cough
5
6
7
8
Sputum production
9
10
11
12
Fatigue
13
14
15
16
Symptom frequency
Rows
Never
Occasional
Frequent
Constant
Shortness of breath
17
18
19
20
Cough
21
22
23
24
Sputum production
25
26
27
28
Fatigue
29
30
31
32
Functional Limitations and Rehabilitation Goals
Activity Tolerance / Functional Limitations
*
Rows
No limitation
Mild limitation
Moderate limitation
Severe limitation
Walking
33
34
35
36
Stairs
37
38
39
40
Self-care
41
42
43
44
Exercise
45
46
47
48
Patient Goals / Desired Outcomes
*
Submit
Should be Empty: