Cardiopulmonary Training Center - Pulmonary Training Starter Form

Your Primary Email*

Your First Name*

Your Last Name*

Your Phone Number*

Emergency Contact Name & Relationship*

Emergency Contact Phone*

Relationship of Emergency Contact*

Name of Referring Physician

If you have a prescription, you will be automatically converted into Pulmonary Rehab Sessions. Don't worry, we are the same team handling everything. We will contact your physician to verify everything.

Select Conditions that apply*

COPD

Recurrent Pneumonia

Bronchiectasis

Bronchitis

OSA

Any Hospital Admissions within the last year for Pulmonary Complications?*

Yes

No

If yes, reason & date of discharge from Hospital.*

Which Program are you enrolling?*

Pulmonary Rehab (Physician Prescribed)

Pulmonary Training (Self Determined - No Prescription)

Can you walk at least 20ft. without assistance*

Yes

No

Reasons you are enrolling.*

Reduce Shortness of Breath

Reduce Anxiety

Improve Cough & Medication Adherence

Recent Hospital Admission

Recent ICU Admission

Exercise Endurance & Strength Training

Become more Active

Nutritional Guidance

Behavioral Changes (Eat better, quit smoking, etc.)

Are you on Prescribed Oxygen?*

Yes

No

If yes, how many liters?

How soon would you like to start?