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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