AMBER'S DAILY THERAPY JOURNAL
Please complete this form each day of the week, even if you did not participate in rehab. This form will be reviewed by your assigned clinician in order to monitor your progress and status in our program. Please be sure to include any complications, goals, or questions that you may have. If you are experiencing any pain during therapy, and/or go above a 7 on the breathing scale, please report it to your assigned clinician as soon as possible.
*IF THIS IS A TRUE EMERGENCY, PLEASE GO TO YOUR NEAREST EMERGENCY ROOM OR DIAL 911*
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NAME *
DATE
MM
/
DD
/
YYYY
DATE OF BIRTH *
MM
/
DD
/
YYYY
WHO IS YOUR ASSIGNED CLINICIAN? *
SPO2% *
HOW MANY LITERS OF 02? *
TEMPERATURE (°F) *
PULSE RATE *
CURRENT WEIGHT *
BLOOD PRESSURE
HOW FAR DID YOU WALK TODAY? *
PLEASE SPECIFY FEET, STEPS OR MILES.
DID YOU RIDE YOUR BIKE TODAY? IF YES, FOR HOW LONG? *
HOW BAD WAS YOUR BREATHING TODAY? *
BEST
WORST
DID YOU EXPERIENCE ANY CONGESTION TODAY? IF YES, PLEASE EXPLAIN. *
HOW WELL DO YOU SLEEP AT NIGHT? *
WORST
BEST
DO YOU FEEL YOUR BREATHING HAS IMPROVED SINCE STARTING REHAB WITH HRN? *
INCENTIVE SPIROMETER MEASUREMENT (EX: 500 mL, 1000 mL, ETC.) *
PLEASE RATE YOUR OVERALL THERAPY EXPERIENCE? *
WORST
BEST
DID YOU EXPERIENCE ANY DISTRESS TODAY? *
HAVE YOU DONE YOUR HOMEWORK ON MY NEW LUNGS TODAY? *
HAVE YOU TAKEN A COALA (ECG MONITOR) RECORDING TODAY? (IF NO, PLEASE GO TAKE ONE!) *
DO YOU NEED AN OFFICE STAFF MEMBER TO CONTACT YOU FOR ANY REASON? *
DO YOU HAVE ANY ADDITIONAL COMMENTS OR CONCERNS YOU WOULD LIKE TO ADDRESS WITH YOUR ASSIGNED CLINICIAN?
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