NEW PATIENT QUESTIONNAIRE: COUGH or LARYNGOSPASM
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- Mark Holt
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1 3010 Highland Parkway, Suite 550 Downers Grove, IL Phone: NEW PATIENT QUESTIONNAIRE: COUGH or LARYNGOSPASM Before you fill out this form: If you will wish to save and this form to us once completed, be sure that you are using Adobe Reader XI. Go to Help About Adobe Reader (Windows) or Adobe Reader About Reader (Mac) to check your version. If you use Adobe Reader X or earlier to fill this out and it to us, we will receive a blank form! Thus, if you have version X or earlier of Adobe Reader, you must either update to version XI before filling out and saving this form, or else you may fill out the form and print it out, without saving it electronically. Name Date of birth Age Occupation(s) Primary care physician (name, address) Date Who referred you to this office? Please list anyone to receive a report of today s visit (if any) in addition to physician above: Physician (name, address) Friend Voice teacher Speech pathologist Internet Television Newspaper Hospital Insurance company Professional organization Other 1. Name Phone Address City/State 2. Name Phone Address City/State PROBLEM OVERVIEW When did your coughing or laryngospasm problem begin? At the beginning, what was it that seemed to start the cough or laryngospasms? Please check all that apply. Upper respiratory infection Bronchitis or pneumonia Surgery on my neck Surgery on my chest Do you experience any sensation (even a subtle one) just before coughing or a laryngospasm begins? Yes, and it is like a... (check all that apply) Sudden tickle Sudden dry patch Sudden burning Feeling of a crumb caught in my throat Jabbing or stabbing sensation... and this sensation is typically located at: Are you aware of anything that sometimes triggers your coughing or laryngospasms? Yes; the triggers include (check all that apply): Talking Laughing Breathing cold air Breathing warm air Eating Swallowing Touching a spot on my neck Posture change, especially at night The main trigger is (if there is one): Page 1 of 5; continue please
2 PROBLEM OVERVIEW (CONTINUED) Which of the following, if any, happens to you when you have severe coughing or a laryngospasm? Please check all that apply. (These are common experiences for many with severe coughing or laryngospasms.) I turn red My nose runs I almost throw up I almost pass out My eyes tear up I lose urine I do throw up I do pass out I have sudden, intense difficulty breathing (laryngospasm) I have broken one or more ribs Please estimate about how many coughing episodes you have each day (keep in mind that one episode could be short or long, from just one isolated cough to a prolonged series of coughs). Total number of episodes per day (of any duration): Number of episodes per day that last at least 5 seconds: Number of episodes per day that last at least 20 seconds: On average, how many times per day do you have a laryngospasm attack? Daytime: Nighttime: Most people with your problem say that it is roughly the same week after week. Some, however, notice periods of greater or lesser severity. Which is the case for you? Please check the answer that best applies. Roughly the same since onset Varies from month to month Varies from week to week May have long periods that are relatively symptom-free If your cough or laryngospasm varies, is there any discernible pattern? Please check all that apply. The problem worsens following an upper respiratory infection (e.g., a cold) The problem seems to be tied to the change of seasons t applicable (the problem doesn t vary) In what ways has this problem affected you? Please check all that apply. It hasn t I just carry on and cope. I limit talking. I avoid public events when possible, for fear of making a disturbance with my coughing. I sleep alone so as not to disturb my bed partner. I ve lost my job because of my coughing. I ve had to change jobs because of my coughing. Click on the number on the scale below which indicates how severe your problem seems to you. Minor annoyance Moderate Ruining my life How motivated would you say you are to solve this problem? t motivated Moderately Extremely Is there anything else you would like to say about your problem? Page 2 of 5; continue please
3 What tests have you had for your problem? For each test you ve taken, please indicate the test result. Test Chest x-ray CT scan MRI Pulmonary function test Bronchoscopy 24-hour acid test Esophagoscopy Allergy test PAST DIAGNOSES AND TREATMENTS How many doctors do you think you have seen specifically for this problem? How many in each of the following specialties? Please check all that apply and give a number for each. Family doctor: Internist: Pulmonologist: Ear, nose, and throat: Psychiatrist: Allergist: Speech pathologist: rmal result or Abnormal result What are you told is the cause of your cough or laryngospasms? Which of these medications have you previously tried? Please check all that apply. Asthma inhalers Acid reflux medication Cough suppressant Antibiotics Expectorant Topical anesthetic Antihistamine (allergy) Amitriptyline (Elavil) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Other 1: Other 2: Other 3: Did any medication ever seem to help noticeably? Yes (which ones, and how much did they help?): Medication: Reduction of symptoms (1 to 100%): Medication: Reduction of symptoms (1 to 100%): Have you tried any other treatments for your problem? Yes; I have tried (check all that apply): Hypnosis Acupuncture Herbal remedies Vitamins Did any of the above alternative treatments seem to help? Yes (list any that helped): Treatment(s): Page 3 of 5; continue please
4 PAST DIAGNOSES AND TREATMENTS (CONTINUED) Are you currently on or have you ever taken an ACE inhibitor generally used for blood pressure control? Yes (check all that apply): Accupril (Quinapril) Inhibace (Cilazapril) Prinivil/Zestril (Lisinopril) Aceon (Perindopril) Lotensin (Benazepril) Univasc (Moexipril) Altace (Ramipril) Mavik (Trandolapril) Vasotec (Enalapril) Capoten (Captopril) Monopril (Fosinopril) Enalaprilat MEDICAL HISTORY Check all that apply. ne apply Heart attack Diabetes Lung disease Liver trouble Heart failure Stroke HIV Hepatitis High blood pressure Seizures AIDS Thyroid Osteoarthritis Mental illness Tuberculosis Bleeding Rheumatoid arthritis Kidney stones Asthma Anemia Kidney failure Blood clot in leg Blood clot in lung Cancer Gout Osteoporosis Alcoholism Stomach ulcers GERD/Acid reflux Allergies Serious injury (explain): SURGICAL HISTORY List previous procedures you have had, if any. ne Operation Surgeon Date FAMILY HISTORY Check all that apply. ne apply Stroke Arthritis Mental illness Alcoholism Heart trouble Gout Kidney trouble or stones Seizures High blood pressure Bleeding disorders Spine problems Diabetes Chronic cough Asthma GERD/Acid reflux Neurological disorder: Psychiatric disorder: Cancer: Page 4 of 5; continue please
5 List medications you take, if any. MEDICATIONS ne Do you have any allergies or adverse reactions to medications?, none Yes (please list): Do you have a living will? Yes SOCIAL HISTORY Tobacco use: Never If current: If former: Cigarettes, packs/day Cigarettes, packs/day for years for years Cigar Chew Cigar Chew Pipe Pipe Quit when? Alcohol use: ne at all 1 3 beverages per week 4 8 beverages per week 8+ beverages per week Caffeinated beverages per day: Total fluids (in cups) per day: REVIEW OF SYSTEMS Check all that apply. Reading glasses Change of vision Loss of hearing Ear pain Toothache Gum trouble sebleeds Frequent headaches Dizziness Blackouts Seizures Numbness or tingling ne apply Abnormal heartbeat Heart or chest pain Chronic pain Arthritis Calf cramps with walking Swollen ankles Cold intolerance Recent weight change Poor appetite Difficulty swallowing Stomach pain Nausea/vomiting Fever or chills Frequent urination Burning on urination Difficulty urinating Frequent constipation Hemorrhoids Skin rash Hot or cold Irregular periods Frequent spotting Nervous Ulcers Heartburn Acid belching Morning sore throat Morning cough Morning mucus Hoarseness Breathing problem Snoring Breath-holding at night Thank you for filling out this questionnaire. When you are finished, please either save and it back to us (again, only possible if you are using version XI of Adobe Reader) or else print it out at home and bring it when you come in. Page 5 of 5
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