Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

Available Forms

ADULT Telemedicine Patient Consent Form (Dr Sunil Lalla patients) CHILDREN < 3 yearsM-Chat Form (Children age < 3 years) CHILDREN Annual depression screening PHQ 9 (Children < 18 years) CHILDREN Registration form Dr Bharti Lalla (New Patient) CHILDREN Sports Physical Form CHILDREN Tuberculosis Questionnaire (Children < 18 years) Immigration (New Patient) Immigration (New Patient) SPANISH Six min WALK ADULT Medical History (New Patient) Dr. Sunil Lalla Sleep History (Initial history) ADULT Registration form Dr S Lalla (New Patient) Sleep apnea (Epworth sleepiness scale)

Six min WALK

SUNIL LALLA, MD FCCP

Six Minute Walk

First Name *

Last Name *

Date of Birth: *

Date of Completion: *

BASELINE PRE TEST

Time

Heart rate

Dyspnea

(Borg scale, 0-10)

Fatigue

(Borg scale, 0-10)

SpO2

POST - TEST

Time

Heart rate

Dyspnea; (Borg scale, 0-10)

Fatigue (Borg scale, 0-10)

(Borg scale, 0-10)

Oxygen Saturation:

Supplemental O2 during the test?

88% or less? How much O2 needed to recover?

Flow L/ min. NC

Stopped before 6 minutes?

Time stopped before 6 mins

min sec

Reason test stopped

Paused during test?

Number of pauses

6 Minute Walk Page 2

First name *

Last name *

Date of birth *

6 MWT results in meters *

Lap counter: place a check mark below for each 28 m lap

Number of laps ______ � 28 m FM, 20 m CC, 30 m SP + ______m (final partial lap) = _____ m (total distance waked in 6 min)

Did the patient experience any pain or discomfort during the test? *

Other symptoms at end of test: *

Angina

Dizziness

Hip pain

Leg pain

Calf pain

None

Rest Room Air Oxygen Saturation *

Exercise Low Oxygen Saturation *

Exercise FIO2 (lpm) *

Test Administrator *

Physician: SUNIL LALLA, MD, FCCP

* Required field