Annexure- 1

Assessment Tool

PALLIATIVE CARE ASSESSMENT FORM

NAME:

AGE:SEX: Male/ Female

AADHAAR NO:                                                                           ABHA:
ADDRESS:
CONTACT DETAILS:
LAND LINE:
MOBILE NO:

SYMPTOMS	DURATION
COUGH
EXPECTORATION
WHEEZE
CHEST PAIN
DYSPNOEA
HEMOPTYSIS
FATIGUE

 

 

 

 

 

 

 

 

 

 

CO-MORBIDITIES	DURATION
ANAEMIA
DIABETES
IHD
BRONCHIAL ASTHMA
COPD
PNEUMOCONIOSIS
BIOMASS EXPOSURE
HIV

 

PERSONAL HABITS	DURATION
SMOKING
ALCOHOL
SUBSTANCE ABUSE

VITALS:
Height (cm)    :
Weight (kg)    :                                                  BMI:

Respiratory Rate:                                         Spo2 in Room air:      
Pulse Rate:                                                     Pedal Oedema:
Blood pressure(mmHg):    Clubbing:

 

 

Chest Xray Findings
Cavity
Parenchymal Fibrosis
Bronchiectasis
ILD
Collapse
Pleural-Complications
Mass Lesion
Aspergillosis / Fungal Diseases

ABG:

pH:    Pco2:    
PaO2:    HCo3:    

ECG:                                     ECHO:

SPIROMETRY:

 

Parameters	Pre	Post	Percentage %
FEV1
FVC
FEV1/FVC
FEV25-75

6 MWT:    
DLCO:    
CPET:

CT Chest:

Biochemistry:                  Blood sugar:         Urea:          Creatinine:

PSYCHOLOGICAL ASSESSMENT

HQL TB Specific Questionnaire EUROHIS-QOL62

Please listen to the questions with regards to quality of life and pick the best option for you. We ask that you think about your life in the past 2 weeks.
Questions    Options    Response
1. How would you rate your quality of life?    A. Very poor    
    B. Poor    
    C. Neither good nor bad    
    D. Good    
    E. Very good    

2. How satisfied are you with your health?    
A. Very dissatisfied    
    B. Dissatisfied    
    C. Neither satisfied nor dissatisfied    
    D. Satisfied    
    E. Very satisfied    

3. Do you have enough energy for everyday life?    A. Not at all    
    B. A little    
    C. Moderately    
    D. Mostly    
    E. Completely    
4. How satisfied are you with your ability to perform your daily living activities?    A. Very dissatisfied    
    B. Dissatisfied    
    C. Neither satisfied nor dissatisfied    
    D. Satisfied    
    E. Very satisfied    
5. How satisfied are you with yourself?    A. Very dissatisfied    
    B. Dissatisfied    
    C. Neither satisfied nor dissatisfied    
    D. Satisfied    
    E. Very satisfied    
6. How satisfied are you with your personal relationships?    A. Very dissatisfied    
    B. Dissatisfied    
    C. Neither satisfied nor dissatisfied    
    D. Satisfied    
    E. Very satisfied    

 

7. Have you enough money to meet your needs?    
A. Not at all    
    B. A little    
    C. Moderately    
    D. Mostly    
    E. Completely    
8. How satisfied are you with the conditions of your living place?    A. Very dissatisfied    
    B. Dissatisfied    
    C. Neither satisfied nor dissatisfied    
    D. Satisfied    
    E. Very satisfied    

PROVISIONAL DIAGINOSIS:
Pulmonary/ Extra pulmonary TB……………..Active/ Treated
Anemia
Malnourishment
Respiratory Insufficiency         Type I                 Type II
Spirometry:    Obstructive/ Restrictive/ Mixed
Functional status:
Mental status    HQL:

Plan of action:
1.    Inpatient / Outpatient
2.    Nutritional supplementation
3.    Oxygen supplementation
4.    Pulmonary rehabilitation
5.    Yoga
6.    End of life care