Clinical Information Form – Lung Foundation of Malaysia

        
            
                
                    LFM Clinical Information Form for Funding Application
                    *To be filled up by the referring Physician
                
                
                
                
                    Patient Demographics
                    
                    
                        
                            Patient's Full Name *
                            
                        
                        
                        
                            I.C. Number *
                            
                        
                    
                    
                    
                        
                            Age *
                            
                        
                        
                        
                            Gender
                            
                        
                    
                    
                    
                        Address *
                        
                    
                    
                    
                        
                            Telephone No. *
                            
                        
                        
                        
                            Hospital Registration No. *
                            
                        
                    
                
                
                
                
                    Diagnosis
                    
                    
                        Primary Diagnosis *
                        
                    
                    
                    
                        Other Diagnosis (Comorbidities)
                        
                    
                    
                    
                        Date of Diagnosis
                        
                    
                
                
                
                
                    Clinical Investigations
                    
                    
                        Lung Function Test
                        
                            
                                FEV1 (L)
                                
                            
                            
                            
                                FVC (L)
                                
                            
                            
                            
                                FEV1/FVC Ratio (%)
                                
                            
                        
                        
                        
                            
                                Test Date
                                
                            
                        
                    
                    
                    
                        Blood Gas (Arterial)
                        
                            
                                pH
                                
                            
                            
                            
                                pCO2 (mmHg)
                                
                            
                            
                            
                                pO2 (mmHg)
                                
                            
                        
                        
                        
                            
                                HCO3 (mmol/L)
                                
                            
                            
                            
                                BE (mmol/L)
                                
                            
                            
                            
                                SpO2 (%)
                                
                            
                        
                        
                        
                            
                                Test Date
                                
                            
                        
                    
                    
                    
                        Sleep Study (Polysomnography)
                        
                            
                                Date of Sleep Study
                                
                            
                        
                        
                        
                            
                                AHI (events/hour)
                                
                            
                            
                            
                                ODI (events/hour)
                                
                            
                        
                        
                        
                            
                                Lowest SpO2 (%)
                                
                            
                            
                            
                                Time SpO2 below 88% (minutes)
                                
                            
                        
                    
                
                
                
                
                    Indication for Ventilatory/Oxygen Support
                    
                    
                        Clinical Indication *
                        
                    
                    
                    
                        
                            Type of Equipment Applied *
                            
                        
                        
                        
                            If Multiple/Specify
                            
                        
                    
                    
                    
                        Duration of Support Required *
                        
                             24 Hours
                             Sleep & Part of the Day
                             During Sleep Only
                        
                    
                    
                    
                        
                            Oxygen Prescription (if applicable)
                            
                        
                    
                
                
                
                
                    Referring Physician Information
                    
                    
                        
                            Name of Referring Physician *
                            
                        
                        
                        
                            I.C. Number *
                            
                        
                    
                    
                    
                        
                            Phone Number *
                            
                        
                        
                        
                            Email *
                            
                        
                    
                    
                    
                        
                            Healthcare Facility
                            
                        
                        
                        
                            Specialty
                            
                        
                    
                    
                    
                        
                            Date *
                            
                        
                    
                
                
                
                
                    Medical Report Submission
                    
                    
                        Please submit a summary of applicant's medical report. The medical report must be signed or verified by the respiratory consultant in charge.
                    
                    
                    
                        Upload Medical Report (PDF only) *
                        
                        Maximum file size: 5MB
                        
                    
                    
                    
                        
                            
                            I confirm that the medical report is complete, accurate, and verified by the respiratory consultant *
                        
                    
                
                
                
                
                    Certification
                    
                    
                        
                            
                            I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge *
                        
                    
                    
                    
                        
                            
                            I consent to the sharing of this information with relevant healthcare providers for the purpose of patient care