6 Minute Walk Test
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who is your assigned Respiratory Therapist?
Alex Grichuhin
Melanie Klein
Pre - Blood Pressure
120/80
Post - Blood Pressure
120/80
Start of 6MWT
O2 Liters
SpO2 Percent
Heart Rate
BORG
PAIN
3 Min of 6MWT
O2 Liters
SpO2 Percent
Heart Rate
BORG
PAIN
6 Min of 6MWT
O2 Liters
SpO2 Percent
Heart Rate
BORG
PAIN
Total Laps
Distance Per Lap (Ft)
Incentive Spirometer Reading
mL
Any additional Comments?
Submit
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