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Pulmonary Therapy Assessment Form (TAF)
Pulmonary Therapy Assessment Form (TAF)
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Address
*
Address line 2
State / Province / Region
*
City
*
Zip
*
Date of Birth
*
Day/Month/Year
Email
*
We won't rent, sell or barter your email address to third parties
Please list your primary and supplemental insurance (if applicable)
On average, how bad is your breathing?
Selected Value:
1
1 being the best and 10 being the worst
Rate your pain on an average day
Selected Value:
1
1 being the best and 10 being the worst
Rate your sleep
Selected Value:
1
1 being the best and 10 being the worst
Select current symptoms (check all that apply)
COPD
On oxygen?
COUGHING SPELLS
RUNNY NOSE
PNEUMONIA
SLEEP APNEA
SMOKING
DIARRHEA
OUT OF BREATH QUICKLY
DIABETES
DIFFICULTY WALKING
DIFFICULTY WITH STAIRS
BALANCE ISSUES
SHOULDER PAIN
BACK PROBLEMS/ PAIN
TINGLY HANDS AND OR FEET
POOR DIET
OVERWEIGHT
Dietary, nutritional or weight issues?
STOMACH OR INTESTINAL PROBLEMS
SWOLLEN OR PAINFUL KNEES
COLD HANDS
CONCENTRATION
RECURRENT HEADACHES
STRESS
DEPRESSION
HIGH BLOOD PRESSURE
DISEASES OF THE ARTERIES
HEART PALPITATIONS
HEART DISEASE
CHEST PAIN
SLEEPING PROBLEMS
FOOT PAIN
LEG(S) PAIN
JOINT PAIN/SWELLING
BEING BULLIED
Have you been diagnosed with COPD
*
Yes
No
If yes, how severe is your COPD?
*
Mild
Moderate
Severe
Very Severe
Not Sure
Not Applicable
Are you a previous smoker? If so, for how long?
*
How many years has it been since you quit? (please type "currently" if you have not yet quit)
What goals would you like to achieve out of pulmonary rehab?
*
Height
Weight
Name of your Pulmonologist (Primary doctor if no pulmonologist)
Doctor's office number
Other/Notes/Concerns
EMERGENCY CONTACT INFORMATION - PLEASE LIST A NAME & RELATION TO YOU
*
Emergency Contact's Phone Number
*
How long has it been since your last sleep study?
*
Less than 3 years
More than 3 years
I have never had a sleep study
How did you hear about us?
Facebook
My Doctor
Internet
Friend
Other
I have read the Disclosure Agreement, and Agree to the Terms and Condition of this site. I am well aware of this program and I may be disclosing possible personal information to HRN (Home Rehab Network) To formulate an Interactive Therapy program.
*
I agree
Do you understand Practitioners will never enter your home physically but digitally through your TV or mobile devices and this form is just an assessment so our doctors and Respiratory therapists can know your situtation and or complications?
*
I understand
By filling this form, you understand that you are asking HRN's staff and practitioners to possibley qualify you or your family member to be in our full Pulmonary Rehabilitation program that you will participate in your home on your time?
*
I understand
Representative who filled this form: (Self/Spouse...)
Submit
