Daily Journal
Please complete this form each day of the week, even if you did not participate in rehab. This form will be reviewed by your assigned clinician in order to monitor your progress and status in our program. Please be sure to include any complications, goals, or questions that you may have. If you are experiencing any pain during therapy, and/or go above a 7 on the breathing scale, please report it to your assigned clinician as soon as possible.

IF THIS IS A TRUE EMERGENCY, PLEASE GO TO YOUR NEAREST EMERGENCY ROOM OR DIAL 911
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Full Legal Name
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Date of Birth
use this format: MM/DD/YYYY
If your device has difficulty with this question, please skip it and let us know in the additional comment section
Who is your assigned clinician?
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SPO2%
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How many Liters of Oxygen are you using today? (If none just leave blank)
What is your pulse rate
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Enter your blood pressure (ex 120/70) *
Enter your current weight (lbs)
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How far did you walk today?
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please specify feet, steps, or miles
Did you ride your bike today? If yes, for how long?
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Rate how bad was your breathing today, on a scale of 0 - 10
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0 being the best and 10 being the worst
Did you experience any congestion today? If yes, please explain
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Rate how well do you sleep at night, on a scale of 0 - 10
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0 being the best and 10 being the worst
Do you feel your breathing has improved since starting rehab with HRN?
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What is your Incentive Spirometer volume today? (Best out of three) *
(EX: 500 mL, 1000 mL, ETC.)
Rate your pain, on a scale of 0 - 10
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0 being the best and 10 being the worst
Have you experienced any distress today?
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Have you done your homework on My New Lungs today?
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How many times have you used your Delta-V today?
Do you need an office staff member to contact you for any reason?
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Please rate your overall therapy experience on a scale of 1 - 5
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  5 being the best and 1 being the worst
Do you have any additional comments or concerns you would like to address with your assigned clinician? (optional)
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This form was created inside of Alexander Grichuhin.