Current Vitals

Current Vitals Form

Please complete this form prior to your appointment. Your Respiratory Therapist will review the information to monitor your progress and status in our program. Be sure to include any complications, goals, or questions you may have.

If you experience pain during therapy or your breathing scale exceeds 7, notify your Respiratory Therapist immediately.

If you are having a medical emergency, please dial 911 or go to your nearest emergency room immediately.

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General Information

Is Pulse Can

Full Legal Name *

First

Last

Date Of Birth *

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Who Is Your Respiratory Therapist? *

• Alexander Grichuhin, RRT-RCP
• Melanie Klein, RRT-RCP
• Jacqueline Stokes, RRT-RCP

BORG Scale (How Out Of Breath Do You Feel?) *

No Difficulty Breathing Extremely Out Of Breath
0	1	2	3	4	5	6	7	8	9	10

Rate Your Pain *

No Pain Extreme Pain
0	1	2	3	4	5	6	7	8	9	10

Vitals

Systolic Blood Pressure *

The TOP NUMBER of your blood pressure reading (e.g. 120)

Diastolic Blood Pressure *

The BOTTOM NUMBER of your blood pressure reading (e.g. 70)

How Many Liters Of Oxygen Are You Using Today? *

Enter 0 (zero) if none

What Is Your Incentive Spirometer Volume Today? *

Best out of three (e.g. 500 mL, 1000 mL, etc.)

Oxygen Reading On Your Pulse Oximeter (SpO2%) *

(After 30 seconds)

What Is Your Pulse Rate? *

Found on your Pulse Oximeter

Can You Participate In Therapy Today? *

• Yes
• No

Please Provide The Reason You Can't Participate In Therapy Today *

Acknowledgments (Required)

Acknowledgment 1 *

• I confirm that the information I entered above is accurate and current (within the last hour).

Acknowledgment 2 *

• I understand and acknowledge that Home Rehab Network LLC (HRN) is not liable for any adverse events that may occur due to the omission of any requested vital signs.

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