Pulmonary Therapy Assessment Form (TAF) – Home Rehabilitation Network

Name*

First

Last

Address*

Street Address Line 2 City State / Province / Region Postal / Zip Code

Date of Birth*

day

month

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)*

Rate your pain in an average day. (10 is the worst)

Rate Your Sleep (0-5 with 5 being the best)

Have you been diagnosed with COPD?*

Yes

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

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...)