Vital Capacity Assessment Form
Use this form to record basic assessment details, breathing-related symptoms, and notes for a vital capacity evaluation. Do not include sensitive personal or medical identifiers.
Respondent Information
Full Name
*
First Name
Middle Name
Last Name
Age or Age Range
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Assessment Context
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Assessment / Primary Concern
*
Current Breathing Difficulty or Respiratory Symptoms
*
No current symptoms
Mild symptoms present
Moderate symptoms present
Severe symptoms present
Vital Capacity Symptom and Function Checklist
Shortness of breath at rest
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Shortness of breath during activity
*
None
1
2
3
4
5
6
7
8
9
Severe
10
1 is None, 10 is Severe
Common limiting symptoms during breathing effort
Chest tightness
Cough
Wheezing
Fatigue
Lightheadedness
Other
Assessment Notes and Expected Outcome
Additional Notes or Observations
Expected Next Step / Follow-up Recommendation
No follow-up needed
Monitor symptoms and reassess later
Schedule clinical review
Refer to specialist
Other
Submit
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