Oxygen Therapy Device Evaluation Form
Use this form to evaluate a patient's oxygen therapy device needs, current usage, and follow-up requirements.
Patient and Evaluation Context
Patient Full Name
*
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis or Reason for Evaluation
*
Referring Clinician or Facility Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Oxygen Therapy Details
Current oxygen delivery method/device type
*
Please Select
Nasal cannula
Simple face mask
Non-rebreather mask
Oxygen concentrator
Portable oxygen cylinder
Venturi mask
Tracheostomy oxygen setup
Other
Prescribed oxygen flow rate or setting (L/min or device setting)
*
Frequency of use
*
Continuous
Intermittent
During sleep only
With exertion only
As needed
Other
Mobility or travel needs related to device use
No special needs
Needs portable device for short trips
Requires extended battery or cylinder supply
Needs assistance with transportation
Uses device while traveling
Other
Clinical Evaluation and Follow-Up
Observed tolerance or concerns with current device use
Desired evaluation outcome or recommendation request
*
Continue current device
Adjust settings
Change device type
Additional clinical review
Other
Submit
Should be Empty: