Respiratory Management Record

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Step 1 - My Information

Step 1
My information

Step 2
My Health Professionals

Step 3
My Treatment

Step 4
My Equipment and Management

You may wish to have your respiratory therapist assist you in completing this form.
Complete this online form in order to receive a PDF copy of your Personal Respiratory Care Record. You will be able to save it on your device, or print it. Your Respiratory Care Record will be sent to the email address that you provide below, after the online form is submitted.

Required fields are indicated with an " * " and bordered in red.

Name:

Email:

NOTE - Your record will be sent to this email address

Birth Date:

Diagnosis:

Home Hospital:

My substitute decision maker is:

My Power of Attorney for Personal Care is:

I have Advanced Directives in place:

Yes No

At Home I Require (check all that apply):

BIPAP

CPAP

Ventilation by Tracheostomy

Cough Assist

Lung Value Recruitement

Portable Suction

Oxygen

Other :

How I Communicate (check all that apply):

Speech

In Writing

Speaking Device

Via my Caregiver

With a Bell

Tablet/Smartphone

Other:

I am able to use a call bell:

Yes No

I need assistance with my breathing treatments:

Yes No

Important! My caregiver(s) and I are extremely knowledgeable about my condition, treatment needs, and equipment. Please work with us. Having my knowledgeable caregiver(s) with me during my hospitalization is very important to me.

Authorization to Speak with Caregiver(s)

I authorize you to consult with my caregiver(s) (family, friend, or home health personnel) with no privacy or timeframe restrictions.

Caregiver Name:

Phone:

Caregiver Name:

Phone:

Caregiver Name:

Phone:

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