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Mon - Fri : 9:00 - 6:00 EST
1-800-341-5838 or 410-871-4601
hrn@hrn.center
MyNewLungs
Video Library
Delta-V
Lung Trainer
Home
Services / Products
HRN Programs
MyNewLungs Video Library
Delta-V Lung Trainer
Youtube Highlights
About Us
Blog
Team
Testimonials
Careers
Contact
Contact Us
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Pulmonary Therapy Assessment Form (TAF)
Pulmonary Therapy Assessment Form (TAF)
THERAPY ASSESSMENT FORM (TAF)
If you are a new patient, please review the disclaimer by clicking on the button labeled "Terms and Conditions Disclaimer" found on the bottom of this page. If you are unsure on filling out parts of this form please contact our office at 410-871-4601.
Name
*
First
Last
Address
*
Street Address Line 2
City
State / Province / Region
Postal / Zip Code
Date of Birth
*
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02
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day
/
January
February
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month
/
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1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
year
Phone-Area Code
*
Area Code
-
Phone Number
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 currently on a scale of 1-10, 10 being the worst?
*
Good
1
2
3
4
5
6
7
8
9
10
Bad
Rate your pain in an average day. (10 is the worst)
0
0
10
Rate Your Sleep (0-5 with 5 being the best)
Select value
0
1
2
3
4
5
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
How severe is your COPD?
*
Mild
Moderate
Severe
Very severe
Not sure
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've 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 maybe 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
Reset