| DEFAULT REASON FOR REQUEST |
(HOME OXYGEN)
O2@ LPM with exercise of:
2. PRESCRIPTION FOR HOME OXYGEN
LPM @ Rest:
LPM Continuous:
LPM During Exercise:
LPM Exercise Only:
LPM @ Night:
LPM Night Only:
REASON FOR REQUEST (complaints and findings):
LPM Night Only:
3. PRIMARY DELIVERY SYSTEM
[] Compressed Gas [] Concentrator [] Liquid System
4. ADDITIONAL ITEMS
[] (steel) Portable Cylinders [] (Aluminum) Portable Cylinders
Tank Size Quantity per Month
----- -----
----- -----
[] Conserving Device (Type):
[] Nasal Cannula
[] Oxygen Mask
[] Trach Mask
[] Humidification
[] Other (e.g., cart, shoulder bag, etc.):
DELIVERY LOCATION:
5. LOGISTICS
[] Outpatient [] Inpatient (Discharge Date):
[] Patient requires portable O2 for transport home
[] Patient requires recertification of prescription and follow-up
appointment: [] 6 months [] 12 months
1. RESULTS OF ARTERIAL BLOOD GASES OR PULSE OXIMETRY
Date of last visit:
Date of next visit:
6. Does patient have advance directive on file? [] Yes [] No
Room Air at Rest:
Room Air with Exercise:
O2@ LPM of:
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