Pulmonary Questionnaire

 

This pulmonary questionnaire consisting of 21 questions was developed by Gina Thomas, a Respiratory Therapist from Sequoia Hospital in Redwood City, California, in conjunction with advisors at Stanford University. Answers obtained from people responding to the questionnaire are designed to build a database which will help to implement pulmonary rehabilitation programs for those recovering from ARDS.

 


Note: If you have problems using this form, please click here -->  Old survey

Questions in Section A are optional, you can answer all, some, or none.
Please answer all the questions in Section B 

Please use your mouse to move from one question to the next as hitting the enter key will automatically submit the form.
Then submit the form.

Section A

Tell us how to get in touch with you:

Name
E-mail
Confirm E-mail
Telephone

Section B

1.) Did you have a pneumothorax and chest tube?

Yes
No

2.) What was your admitting diagnosis (DX)?


3.) Did you have surgery? If so, what kind?

Yes
No


4.) Length of time (days) you were mechanically ventilated and what type of ventilation did you receive


5.) Did you require a tracheotomy?

Yes
No

6.) Did you require dialysis?

Yes
No

7.) Total days you were hospitalized?


8.) How many days/months/years since you developed ARDS?


9.) Did you have a pulmonary condition prior to developing ARDS (i.e. asthma, bronchitis, emphysema).

Yes
No


10.) Did you require oxygen for home use upon discharge? If so, what was the prescription - Liters per minute and hours per day?

Yes
No


11.) Are you currently using oxygen? If so, hours/day and lpm (liters per minute).

Yes
No


12.) Are you taking medication for your lungs? Bronchiodialators, steroids, etc..

Yes
No


13.) Post-ARDS were you placed on steroids? If so, what dosage?

Yes
No


14.) Post-ARDS, were you able to resume all activities you previously performed?

Yes
No

15.) What activities have you NOT been able to resume?


16.) Did you receive any inpatient rehabilitation, such as physical therapy, while hospitalized?

Yes
No

17.) Did you receive any pulmonary rehabilitation post-ARDS?

Yes
No

18.) Were you transferred to another facility other than the hospital where you developed ARDS for pulmonary rehabilitation?

Yes
No

19.) Are you currently exercising? If yes, type, frequency, and duration.

Yes
No


20.) Have you had any Pulmonary Function Tests post-ARDS?

Yes
No

21.) If yes to number 20, do you know your percent of predicted FVC (forced vital capacity), FEV1 (forced expiratory volume in one second) and diffusing capacity?



 

This release hereby authorizes ARDS Support Center, Inc., or their agents, to examine, make copies of, and/or share any and all medical information with the ARDS Support Center Board of Medical Advisors that I have supplied on this questionnaire. 

Agree 

Disagree


Type Full Name Here


 

Thank you for taking the time to complete the survey !


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Copyright 2000 ASC.  All rights reserved.
Revised: October 25, 2003

 

 

 

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