Cardiopulmonary Rehabilitation Assessment
Form Filling and Clinical Assessment Guidance for Physiotherapists
Purpose of the Form
This form is designed to provide a comprehensive baseline evaluation for patients entering cardiopulmonary rehabilitation across OPD, IPD, ICU, step-down, and rehabilitation settings. It integrates cardiac, pulmonary, functional, and musculoskeletal domains to support risk stratification, individualized exercise prescription, monitoring, and outcome evaluation.
The structure aligns with the functional framework of cardiopulmonary rehabilitation and supports interdisciplinary communication, audit, and medico-legal documentation.
S – SUBJECTIVE ASSESSMENT
The subjective section captures the patient narrative, symptom burden, functional baseline, and clinical context.
Patient Identification
How to fill
- Tick the current care setting (OPD, IPD, ICU, step-down, rehab).
- Record patient name, UHID, age, sex, and date/time of assessment.
Clinical guidance
Care setting determines rehabilitation intensity and monitoring level. ICU and step-down patients require conservative progression and continuous monitoring, whereas OPD and rehab settings allow structured exercise progression.
Primary Indication
How to fill
Tick the primary cardiopulmonary indication (e.g., post-CABG, post-MI, heart failure, COPD, ILD, asthma, post-COVID, post-ICU deconditioning).
Clinical guidance
This field establishes the dominant physiological limitation and guides the choice of outcome measures, exercise modality, and progression rate.
Referral Source
How to fill
Tick the referring specialty (cardiology, pulmonology, ICU, physician).
Clinical guidance
Referral source provides insight into medical priorities, expected precautions, and follow-up requirements.
Chief Complaints
How to assess
Ask the patient to describe symptoms limiting daily life.
How to fill
Tick all applicable complaints such as breathlessness, fatigue, reduced exercise tolerance, cough, wheeze, chest discomfort, difficulty with ADLs, or fear of exertion.
Clinical interpretation
Fear of exertion is common in cardiac and post-ICU patients and must be addressed through graded exposure and education, not just physical training.
History of Presenting Complaint
How to assess
Clarify onset and progression of symptoms.
How to fill
- Tick onset type (sudden, gradual, post-event).
- Tick course since onset (improving, static, worsening).
Clinical interpretation
Post-event onset suggests recovery-oriented rehabilitation, whereas worsening course may indicate ongoing pathology requiring cautious progression.
Baseline Functional Capacity Prior to Current Illness
How to fill
Tick whether the patient was independent, had limited endurance, or was dependent before the current illness.
Clinical interpretation
Pre-morbid function strongly influences rehabilitation potential and goal realism.
Past Medical History (PMH)
How to assess
Review patient interview and medical records.
How to fill
Tick all relevant cardiac, pulmonary, metabolic, renal, neurological, and obesity-related conditions. Indicate prior hospitalisations and need for ICU, NIV, or ventilation.
Clinical interpretation
Multiple comorbidities increase rehabilitation risk and necessitate closer monitoring and slower progression.
Subjective Symptom Assessment
How to assess
Identify dominant symptoms and their severity.
How to fill
- Tick primary symptoms (dyspnea, fatigue, chest discomfort, cough, wheeze, exercise intolerance).
- Record dyspnea severity using Borg scale.
- Document chest pain presence and type (typical or atypical).
Clinical interpretation
Typical chest pain or disproportionate dyspnea warrants medical review before exercise progression.
O – OBJECTIVE ASSESSMENT
The objective section confirms medical safety, physiological status, and functional capacity.
Medical & Safety Clearance (Mandatory)
How to assess
Review vitals, medical notes, and current symptoms.
How to fill
- Tick fitness for rehabilitation (fit, fit with precautions, not fit today).
- Tick contraindications or high-risk flags such as unstable angina, uncontrolled arrhythmias or BP, resting SpO₂ < 88%, acute infection, PE, or DVT.
Clinical interpretation
Presence of any high-risk flag contraindicates active rehabilitation and requires consultant notification.
Cardiopulmonary History
How to assess
Ask about smoking and review comorbidities and medications.
How to fill
- Record smoking status and pack years.
- Tick comorbidities.
- Tick medications affecting rehab (beta-blockers, bronchodilators, steroids, diuretics).
Clinical interpretation
Medications influence heart rate response, oxygenation, fatigue, and perceived exertion, necessitating reliance on Borg scales in many patients.
Baseline Vital Parameters
How to assess
Measure after adequate rest.
How to fill
Record resting BP, HR, SpO₂, respiratory rate, and oxygen support modality.
Clinical interpretation
These values form the baseline for exercise monitoring and termination criteria.
Functional Classification (Core Section)
A. Cardiac Functional Classification – NYHA
How to assess
Based on symptom limitation during daily activities.
How to fill
Tick NYHA class I–IV.
Clinical interpretation
NYHA class directly determines exercise intensity, supervision level, and progression speed.
B. Pulmonary Functional Group – GOLD (COPD only)
How to assess
Based on symptom burden and exacerbation risk.
How to fill
Tick GOLD A–D if the patient has COPD.
Clinical interpretation
GOLD C–D patients require slower progression, frequent symptom checks, and oxygen surveillance.
Functional Capacity & Outcome Measures
Six-Minute Walk Test (6MWT)
How to assess
Conduct as per ATS guidelines if medically safe.
How to fill
- Tick performed or deferred.
- Record distance walked.
- Record pre- and post-test HR, SpO₂, Borg dyspnea.
- Tick test response.
Clinical interpretation
6MWT distance and physiological response guide aerobic training intensity and progression.
Borg Rating of Perceived Exertion / Dyspnea
How to fill
Record Borg scores at rest, during exercise, and post-exercise.
Clinical interpretation
Disproportionate Borg response indicates poor tolerance or need for regression.
Functional Endurance Interpretation
How to fill
Tick low, moderate, or good tolerance and identify the limiting factor.
Clinical interpretation
Limiting factor (dyspnea, fatigue, desaturation, fear) determines the primary rehabilitation focus.
Musculoskeletal & Postural Screen
How to assess
Observe posture, chest mobility, strength, and balance.
How to fill
Tick relevant findings such as generalized weakness, reduced chest expansion, kyphosis, shoulder restriction, or balance deficit.
Clinical interpretation
Musculoskeletal impairments often limit cardiopulmonary exercise and must be addressed concurrently.
A – ASSESSMENT
Integrated Functional Interpretation
How to fill
- Identify primary limitation (cardiac, pulmonary, deconditioning, or mixed).
- Assign overall risk stratification (low, moderate, high).
Clinical interpretation
This synthesis determines supervision level, monitoring needs, and progression strategy.
Physiotherapy Clinical Impression
How to fill
Provide a concise summary integrating subjective complaints, objective findings, and functional limitations.
P – PLAN
Rehabilitation Goals
How to fill
Tick relevant short-term and long-term goals.
Clinical interpretation
Goals should be measurable, function-oriented, and aligned with patient priorities.
Cardiopulmonary Rehabilitation Plan
How to fill
- Select aerobic modality and intensity.
- Tick appropriate breathing and airway clearance techniques.
- Select strength and endurance components.
- Tick education and self-management components.
- Document frequency and session duration.
Clinical interpretation
Exercise prescription must align with risk category, functional class, and outcome measures.
Safety, Education & Monitoring
How to fill
Tick all education and monitoring components delivered.
Clinical interpretation
Education reduces adverse events, improves adherence, and supports long-term self-management.
Assessor Authentication and MDT Inputs
How to fill
Record assessor name, signature, date/time, and MDT inputs.
Clinical significance
Ensures accountability, continuity of care, and interdisciplinary coordination.
Clinical Summary
The Initial Cardiopulmonary Rehabilitation Assessment form functions as a risk-stratified clinical reasoning tool, linking medical safety, symptom burden, functional capacity, and structured rehabilitation planning. Accurate and thoughtful completion of this form is essential for delivering safe, effective, and outcome-oriented cardiopulmonary rehabilitation