Physician Order Form

Complete this form to refer a patient for pulmonary rehabilitation services.

1Facility Information

Asthma & Lung Center

8555A Knight Rd, Houston, TX 77054

Phone: (713) 839-9473

Fax: (713) 839-9471

2Patient Information

Patient Name

Date of Birth

Phone

Insurance

Subscriber ID

3Clinical Information

ICD-10 Code

Diagnosis

Current Findings

4Goals

Increase activity tolerance and endurance in ADLsIncrease ability to cope with disease and limitationsIncrease knowledge of disease and therapiesDevelop effective breathing techniques

5Therapy Orders

Therapeutic Exercises for Respiratory Diagnoses

Frequency (times/week)

Duration (weeks)

Physical Therapy for Strengthening and Endurance

Frequency (times/week)

Duration (weeks)

6Services Requested

Physical TherapyRespiratory TherapistMSW (Medical Social Worker)Therapeutic ExerciseNutritionBreathing RetrainingADL Assistance/InstructionEducation and TrainingBalance TrainingBronchial HygieneAerosol Medications (if indicated)Pulmonary Function Tests (PFTs)

7Baseline Evaluation Procedures (Optional)

Body Composition AnalysisOxygen TitrationBalance TestingSix Minute Walking TestSpirometry Testing

8Medical Orders

Oxygen Order Required

HHN Treatment (Nebulizer)

AlbuterolAtrovent

Emergency Orders

9Additional Clinical Information

Significant Medical History

Special Instructions / Precautions / Contraindications

Frequency and Duration

Other Orders

10Physician Information

Physician Name

NPI Number

Address

Phone

Fax

Physician Signature

Provide a signature by typing your name, drawing it, or uploading an image.

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Asthma & Lung CenterPulmonary Rehabilitation

Helping people breathe better, move better, and live better through medically supervised pulmonary rehabilitation.

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Physician Order

Services

Pulmonary Rehabilitation
Cardiovascular & Pulmonary PT
Breathing Techniques
Stamina & Strength Building
Lung Function Testing

Contact

8555A Knight Rd, Houston, TX 77054
(713) 839-9473
Mon–Fri: 8AM – 6PM
Sat: 9AM – 1PM