NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
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1 NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus, Type II Emphysema Exposure to TB G.E.R.D. Heart Disease Hiatal Hernia Heart Lung Other Hypercholesterolemia (high cholesterol) Hypertension (high blood pressure) Liver disease Obstructive Sleep Apnea Pneumonia Positive TB skin test in past Pregnant Raynaud's Disease Respiratory Failure, Chronic Rhinitis, Chronic Sleep Apnea, Unspecified Thyroid Disorder Ulcers Past Surgical History
2 Medications (Include inhaled medications, oxygen, and CPAP or BIPAP useage) Medication Dose Dose Intervals (once a day, 2x a day, etc). Allergies Medication/ Misc. Reaction:
3 Medications Continue (Include inhaled medications, oxygen, and CPAP or BIPAP useage) Medication Dose Dose Intervals (once a day, 2x a day, etc).
4 Family History Check what disease run in your family and specific relative? Emphysema Hemophilia Multiple Sclerosis Leukemia Wegene'rs Granuloma Lung Cancer Anemia Lupus Arthritis Malignant Neoplasm Asthma Ovarian Cancer Breast Cancer Rheumatoid Arthritis Bronchiectasis Sarcoidosis Bronchitis Scleroderma Clotting disorder Sickle Cell Anemia Colon Cancer Stroke Cystic Fibrosis Thromboembolic Diabetes Tracheal Cancer Heart Disease Tuberculosis
5 Social History Abestos Exposure yes no Do you keep animals at home? yes no Dust Exposure yes no Employment Status: Occupation: Strong Chemicals Exposure yes no Traveled in last year? (list places and dates) Tobacco use? yes no Never Current smoker Average packs/day Number of years smoking Quit When? Average packs/day Number of years Approximately how many drinks of alcohol do you have per week? Birthplace:
6 Review of Symptoms Other than your breathing problem, please check and describe problems you have experienced in the past three (3) months CONSTITUTIONAL CARDIOVASCULAR NEUROLOGIC Fever Chest Pain Tingling or numbness Loss of appetite Irregular heart beats Altered mental status/ Chills Dyspnea on extertion loss of consciousness weight loss of more than 5 pounds Lower extremity edema Seizures weight gain of more than 5 pounds (swelling at ankles) Sleepiness in the daytime How much? Rapid heart rate MUSCULOSKELETAL (unexplained weigh loss/gain) Heart murmur Muscle pain Night Sweats RESPIRATORY Joint pain Malaise (Unusual fatigue) Shortness of breath Neck pain EYES Cough Back pain Double vision Wheezing Fingers turn white & Dry eyes Chest Wall Pain painful of cold Eye discomfort (irritation) GASTROINTESTINAL Morning stiffness Changes in vision Abdominal pain ENDOCRINE Blurred vision Reflux (gastro esophageal) Polyuria HENT Nausea (Excessive urination) Headaches Constipation Polydipsia Hearing difficulty (loss) Heartburn (Excessive thirst) Dry mouth Diarrhea PSYCHIATRIC Hoarseness GENITOURINARY Anxiety Vertigo (unusual dizziness) Urgency (Frequent urination) Depression Sinus pain Hematuria (blood in urine) Nasal Discharge Irregular Menses HEME-LYMPH Tinnitus (ringing ears) (irregular menstrual periods Easy bleeding Lighteadness/fainting or vaginal bleeding) Easy bruising Nasal Congestion Dysuria (painful urination) lymp node enlargement Postnasal Drip INTEGUMENT Ear pain Rash Other Symptoms: BREASTS Lumps Breast discomfort Skin dryness Itching No Other Symptoms Additonal Comments:
7 Pulmonary History Check all that currently apply Intermittent cough (not related to a common cold) Daytime sleepiness Frequent cough in the morning Postive TB skin test in the past Sputum production: tablespoons per day Exposure to TB Coughing up blood Pneumonia Chest congestion/tightness Shortness of breath Wheezing: During strenuous exercise Following a common cold During moderate exercise With exercise During normal activity Seasonally (spring/fall) While at rest Snoring Awaken at night How many blocks on level can you walk? How many flights of stairs can you climb? Date of last Chest X-Ray Pneumococcal pneumonia vaccine-date Influenza vaccine-date
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