Daily Journal

Daily Journal Form

Please complete this form each day of the week, even if you did not participate in rehab. Your assigned Clinician 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 assigned Clinician 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

Full Legal Name *

First

Last

Date Of Birth *

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Who Is Your Assigned Clinician? *

• Alexander Grichuhin, RRT-RCP
• Melanie Klein, RRT-RCP
• Milly Castillo, 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

How Well Do You Sleep At Night? *

Poor Sleep Sleep Very Well
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)

What Is Your Current Weight? *

Please enter your weight in LBS

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

Questionnaire

Did You Use Your DELTA-V Today? *

• Yes
• No

How Many Times Have You Used Your DELTA-V Today? *

Did You Walk Today? *

• Yes
• No

How Far Have You Walked Today? *

Please specify units (e.g. Feet, Steps, Miles, etc.)

Did You Ride Your Bike Today? *

• Yes
• No

For How Long Did You Ride Your Bike Today? *

Please specify units (e.g. Time, Miles, etc.)

Did You Experience Any Congestion Today? *

• Yes
• No

Please Explain Your Congestion Today *

Additional Information

Please Rate Your Overall Therapy Experience *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Do you need an office staff member to contact you for any reason? *

• Yes
• No

You Scale Congestion

Do You Have Any Additional Comments Or Concerns You Would Like To Address With Your Assigned Clinician?

Acknowledgments (Required)

Acknowledgment 1 *

• I confirm that the information I entered above is accurate and current.

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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