Technician: 

DOS:       DOB: 

Patient Name: 

Greenway ID#:     Age:     Gender: 

Height:  ft   in     Weight:  lb     BMI: 

FITNESS LEVEL

 Out of Shape  Fit  Athletic

Resting HR :  bpm

SPO2 :  %   @    

BODE Index for COPD

FEV (%Predicted)?     6-Minute Walk Distance? 

Modified MRC Dyspnea Scale? 

Modified MRC Dyspnea Scale defined as follows:
0: Dyspneic on strenuous exercise
1: Dyspneic on walking a slight hill
2: Dyspneic on walking level ground; must stop occasionally due to breathlessness
3: Must stop for breathlessness after walking 100 yards or after a few minutes
4: Cannot leave house; breathless on dressing/undressing

Body Mass Index? 

RESULTS

BODE Index:     Estimated 52-Month Mortality in COPD: