Client Name: <<Patient Demographics:Full Name>>	DOB: <<Patient Demographics:DOB>>	
Contact Number: <<Patient Demographics:Phone (Mobile)>>	Gender:<<Patient Demographics:Sex>>	
Address: <<Patient Demographics:Address Line 1>>	<<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Country of Birth: <<Patient Demographics:Country of Birth>>	Language: <<Patient Demographics:Language Preferred>>                     	
Aboriginal or Torres Strait Islander: oYes  o No	Interpreter Required___	
Emergency Contact: Name: _________________________ Ph:___________________
Relationship to Client:  _________________________ 

Medications:_____________________________________________________________________
______________________________________________________________________________________
Patient has own means of transport    o    Yes    o  No    Current walking distance______
Is patient eager to participate              o    Yes    o  No
GP approval to participate in pulmonary rehabilitation      o   Yes        o   No
GP Name:<<Doctor:Name>> 			Ph: <<Doctor:Phone>>
Address:<<Doctor:Address>> , <<Doctor:City>> , <<Doctor:Postcode>> 
Signature: ________________________________Date:<<Miscellaneous:Date>>