Name
	DOB:	
Address	Phone

Mobile	
Has this person ever been an inpatient at The Wesley Hospital?
Date of Last Admission, if known:	Yes  	No 	
Respiratory Diagnosis:

Severity:
	Oxygen Dependent?

If yes, requirements?	
Other Conditions:

		
Recent Investigations (if known):
1.	Spirometry

2.	ABG (room air)

3.	Radiology
	Other Investigations if relevant:	
Medications:

Inclusion Criteria
•	Have stable, moderate to severe COPD (FEV1 < 60%) or other chronic respiratory disease, or have undergone lung volume reduction surgery
•	Be willing and able to participate in weekly sessions of exercise and education over 10 weeks
•	Be prepared to meet achieveable goals
•	Be able to benefit from such a program in terms of increased physical functioning, quality of life issues and self management of condition	Exclusion Criteria
•	Currently smoke
•	Have no achieveable goals
•	Require respite or immediate high level residential care
•	Are not able or willing to participate in a ten week program
•	Severe cognitive impairment
•	Severe psychotic disturbance
•	Current infectious disease risk
•	Musculoskeletal or neurological conditions which prevent gentle exercise
•	Unstable cardiovascular disease	
Does the patient meet the the Inclusion/ Exclusion criteria
Have you discussed the requirement to attend all 10 sessions?
Health Fund Status : 	Yes                        No	
Referring Medical Officer:
Name:
Address:
Phone/ Fax:

Email:
Provider Number:		
Signature:
	Date:	
Patient Referral
Wesley Therapy Service, 451 Coronation Drive, Auchenflower QLD 4066
Ph 07 3232 6190    Fax  07 3232 6189   Email : Wesley-rehab@uchealth.com.au