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
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