Pulmonary Questionnaire
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- Melvyn Bradley
- 7 years ago
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1 Pulmonary Questionnaire NAME: DATE: ADDRESS: DATE OF BIRTH: AGE: SEX: HOME PHONE: WORK: CELL:_ MARITAL STATUS: SINGLE: MARRIED: WIDOW(ER): DIVORCED: SEPARATED: Physician who told you to come here: Phone #: Address: City/State: Family Physician: Phone #: Address: City/State: What is the reason for your visit? ALLERGIES: Allergy:_ Allergy:_ Allergy:_ Reaction: Reaction: Reaction: CURRENT MEDICATIONS: NAME: DOSE FREQUENCY (or give us a list to copy) Do you use oxygen? _ How much: _ If more space is needed, use the back of this page and check here: LAST PNEUMONIA VACCINATION:_ LAST INFLUENZA VACCINATION: MEDICAL PROBLEMS (Check if YOU have had any of the following problems): Asthma Emphysema Diagnosed sleep disorder Atrial fibrillation Heart attack Stroke Blood clots Heart failure Thyroid disease Cancer Kidney disease Valvular heart disease Diabetes Pulmonary hypertension High blood pressure Other: 1
2 Past Surgeries: Do you smoke cigarettes? Yes No Quit If quit, how long ago? For how many years have you smoked cigarettes?... years How many cigarettes per day?... cigarettes Do you use street drugs now? Yes No Have you used street drugs in the past? Yes No Do you drink alcohol? Yes No How many drinks? per day per week Do you drink caffeinated beverages? Yes No How many caffeinated beverages do you drink per day? (Coffee, tea or soda) Where were you born? _ Do you have pets in your home? What is your occupation? Have you been exposed to chemical, toxins, or asbestos in the past? Yes No What were the exposures? Do you exercise? Yes No What kind of exercise and how often? What health problems have occurred in your family? Sister(s) 2
3 Are you CURRENTLY having any of the following health problems? Please check all that apply. GENERAL: Poor appetite. Recent weight loss (within six months) Fevers Weight gain.. Night sweats CARDIOVASCULAR: Chest pain.. Irregular or fast heart beat.. Swelling in the ankles Wake up short of breath at night so that you sit up during the night.. Pain in your legs when walking. Have you had a stress test? EYES, EARS, NOSE, THROAT: Hearing problems.. Sore throat.. Recurrent sinus infections Hoarseness Nasal congestion... Post nasal drip... Runny nose RESPIRATORY: Diagnosed asthma..... Cough with phlegm production Cough with blood.. Wheezing... Shortness of breath with activity Shortness of breath at rest. Dry cough.. Hay fever Exposure to TB.. If you are being seen for a cough, is it: Dry. Are you consistently raising sputum?... ALL THAT APPLY 3
4 What triggers the cough: Time of Day. Day of Week. Related to Eating.. Time of Year Worse when lying down.. GI: Difficulty swallowing solid food.. Difficulty swallowing liquids Heartburn.. Ulcers Diarrhea. Nausea.. Pain in abdomen Blood in stools.. Constipation.. Change in bowel habits. Vomiting Coughing with swallowing ENDOCRINE: Thyroid problems.. Diabetes without insulin Diabetes with insulin. NEUROLOGIC: Headaches. Seizures. Weakness in arms or legs.. Previous stroke (s). Diagnosed Neurological Disorder GENITOURINARY: Frequent urination. Burning with urination. Blood in urine Difficulty starting to urinate. Vaginal discharge.. Last menstrual period was: HEMATOLOGIC: Anemia.. 4
5 Easy bruising. Nose bleeds Frequent infections Enlarged lymph nodes/lumps Current or prior cancer.yes. If yes, what type: MUSCULOSKELETAL: Joint pain. Arthritis. Muscle weakness.. Muscle pain.. Color changes in the fingers when it is cold Curvature of the spine. SLEEP: Do you have a sleep disorder diagnosed?. Snoring at night Stop breathing during sleep.. Falling asleep during the day at inappropriate times. Falling asleep when driving a car or other vehicle Restless legs. SKIN: Skin cancer Skin rash or lumps. BREAST: Breast lumps.. Mammograms Nipple discharge PSYCHIATRIC: Anxiety. Depression Problems with excessive use of alcohol or street drugs Patient s signature: _ Date: Physician s signature: Date: 5
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Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
Westoaks Orthopaedic Associates
Westoaks Orthopaedic Associates Name: Address: Patient ID #: Sex: M [ ] F [ ] Date of Birth: Social Security #: City, State, Zip: Email: [ ] Home [ ] Work [ ] Mobile [ ] Married [ ] Single Referring Physician:
Please complete the Consent Form and the Respirator Certification Questionnaire.
The Occupational Safety and Health Administration (OSHA) Respiratory Protection Standard requires an employee to complete a questionnaire if the employee is required to wear a respirator. You have been
Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip
Texas Sinus Center PATIENT REGISTRATION 1. PATIENT INFORMATION Name Birth date Soc Sec# Address City/State Zip Home Phone Work Phone Cell Phone Marital Status S / M / W / D Student FT / PT Male / Female
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM
ALBANY PLASTIC SURGEONS, PLLC 4 Executive Park Drive Albany NY 12203 (518) 438-1434 PATIENT INFORMATION FORM Today s Date: PERSONAL INFORMATION First Name: Last Name: MI: Address: City: State/Province:
Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects