Section A

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Section B

1.) Did you have a pneumothorax and chest tube?

Yes
No

2.) What was your admitting diagnosis (DX)?

3.) Did you have surgery? If so, what kind?

Yes
No

4.) Length of time (days) you were mechanically ventilated and what type of ventilation did you receive

5.) Did you require a tracheotomy?

Yes
No

6.) Did you require dialysis?

Yes
No

7.) Total days you were hospitalized?

8.) How many days/months/years since you developed ARDS?

9.) Did you have a pulmonary condition prior to developing ARDS (i.e. asthma, bronchitis, emphysema).

Yes
No

10.) Did you require oxygen for home use upon discharge? If so, what was the prescription - Liters per minute and hours per day?

Yes
No

11.) Are you currently using oxygen? If so, hours/day and lpm (liters per minute).

Yes
No

12.) Are you taking medication for your lungs? Bronchiodialators, steroids, etc..

Yes
No

13.) Post-ARDS were you placed on steroids? If so, what dosage?

Yes
No

14.) Post-ARDS, were you able to resume all activities you previously performed?

Yes
No

15.) What activities have you NOT been able to resume?

16.) Did you receive any inpatient rehabilitation, such as physical therapy, while hospitalized?

Yes
No

17.) Did you receive any pulmonary rehabilitation post-ARDS?

Yes
No

18.) Were you transferred to another facility other than the hospital where you developed ARDS for pulmonary rehabilitation?

Yes
No

19.) Are you currently exercising? If yes, type, frequency, and duration.

Yes
No

20.) Have you had any Pulmonary Function Tests post-ARDS?

Yes
No

21.) If yes to number 20, do you know your percent of predicted FVC (forced vital capacity), FEV1 (forced expiratory volume in one second) and diffusing capacity?