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