Pulmonary Rehabilitation Intake Form
Please complete this form to help us assess your eligibility and prepare for your pulmonary rehabilitation program.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Respiratory Diagnosis
*
Please Select
Chronic Obstructive Pulmonary Disease (COPD)
Asthma
Interstitial Lung Disease
Pulmonary Hypertension
Other
Current Respiratory Symptoms (select all that apply)
*
Shortness of breath
Cough
Wheezing
Chest tightness
Fatigue
Other
Smoking History
*
Never smoked
Former smoker
Current smoker
List current medications (separate by commas)
*
Relevant Comorbidities (select all that apply)
*
Heart disease
Diabetes
Hypertension
Obesity
None
Other
Have you been hospitalized for a lung-related condition in the past 12 months?
*
No
Yes, once
Yes, more than once
Submit Intake
Should be Empty: