PULMONARY MEDICINE PATIENT QUESTIONNAIRE

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Transcription:

PULMONARY MEDICINE PATIENT QUESTIONNAIRE Date Name DOB Age Referring Physician What problem brings you to see us today? Have you had any of the following? (Any left blank will be reported in your medical record as negative.) o Shortness of breath o Cough productive of phlegm o Chest pain o Coughing up blood o Dry cough o Wheezing PAST MEDICAL HISTORY Check any of the following illnesses with which you have been diagnosed and provide details in the space provided. Please answer each question. Any left blank will be considered negative in your medical record. o Asthma List any other medical illnesses/diagnoses (use back of page if necessary): o Blood clot in leg (DVT) o Cancer (specific type) o Cirrhosis o Congestive heart failure (weak heart, enlarged heart) o Coronary artery disease (angina, heart attack, heart blockages) o Emphysema or chronic bronchitis o Gastroesophageal reflux disease (GERD) o High blood pressure o Peptic ulcer disease (stomach ulcers) o Pulmonary embolus (blood clot traveled to lung) o Stroke o Thyroid disease (hyperthyroidism, hypothyroidism) o Diabetes o Gallbladder disease o Hepatitis o HIV/AIDS o Pneumonia o Sleep apnea o Tuberculosis

Page 2 PAST SURGICAL HISTORY: List all surgeries you have had in the past and their approximate dates: MEDICATIONS: List all medications you currently take. Include dosage and frequency. Please include all inhalers, insulin and over the counter medications. 1. Dose Times per day How long 2. Dose Times per day How long 3. Dose Times per day How long 4. Dose Times per day How long IMMUNIZATION HISTORY: List approximate date of last immunization. Write N/A if you have never had the immunization. Influenza flu shot Pneumovax pneumonia shot Tetanus ALLERGIES: o check if no known drug allergies List any drugs you cannot take and why (rash, swelling, nausea. etc.) FAMILY HEALTH HISTORY: Lung Disease Heart Disease Other Illnesses Cause of Death Mother Father Brother(s) Sister(s) Children

Page 3 HABITS: Did you ever smoke? o Yes o No If yes, when did you start? Do you still smoke? o Yes o No When did you stop? How many packs per day? Do you drink any alcohol currently? o Yes o No If yes, approximately how much do you drink? Do you have any past history of heavy alcohol use? o Yes o No Do you have any history of abusing prescribed or non-prescribed drugs? o Yes o No Which substance(s)? Last time used? Have you ever abused IV drugs? o Yes o No SOCIAL HISTORY: Marital status: o Single o Married o Divorced o Widowed How many children do you have? Who should be contacted in case of an emergency? Relationship Phone Number What is your occupation now or prior to retirement? How long at occupation? Have you been exposed to any of the following at work? o Asbestos o Bird Feathers o Silica (sand, sandblasting) o Coal Dust o Chemicals (provide details)

Page 4 Review of Systems: Please check if you have had any of the following symptoms or findings recently. Please answer each question. Any left blank will be considered negative in your medical record. Yes No General o o Weakness o o Fever o o Chills o o Tend to be too hot o o Tend to be too cold o o Night sweats o o Weight loss o o Weight gain o o Loss of appetite o o Severe fatigue o o Thirsty o o More hungry than normal Yes No Neurologic o o Frequent headache o o Dizziness/vertigo o o Lightheadedness o o Fainting/passing out o o Weakness arms/legs o o Numbness arms/legs o o Seizures o o Paralysis Yes No EENT o o Blurred vision o o Color blindness o o Hearing problems o o Ringing in ears o o Nasal congestion o o Runny nose o o Nosebleeds o o Sinus infection o o Hoarseness o o Mouth Ulcers o o Neck Pain o o Mass or lump in neck o o Sneezing o o Post nasal drip Yes No Cardiopulmonary o o Chest pain (w/exertion) o o Chest pain (at rest) o o Shortness of breath (w/exertion) o o Shortness of breath (at rest) o o Shortness of breath (lying down) o o Palpitations (heart racing) o o Irregular heart beat o o Wheezing o o Cough o o Coughing up blood o o Pain on deep breathing o o Sleep with more than one pillow under your head at night o o Swelling in the feet Yes No Sleep o o Difficulty falling asleep o o Frequent awakening o o Waking up too early o o Nightmares o o Leg discomfort/restlessness occurring in the evening o o Snoring o o Severe daytime sleepiness o o Interruptions in breathing while asleep o o Waking with shortness of breath Yes No Gastrointestinal o o Pain or difficulty swallowing o o Heartburn/indigestion (frequent) o o Nausea/vomiting o o Diarrhea o o Constipation o o Blood in stools o o Dark, tarry stools o o Abdominal pain o o Vomited blood o o Reflux Yes No Musculoskeletal o o Joint pain/swelling o o Leg swelling o o Back pain o o Muscle pain Yes No Skin o o Rash o o Breast lump/mass Yes No Heme/Onc o o Easy bruising o o Easy bleeding o o Anemia o o Swollen glands Yes No Genitourinary o o Frequent urination o o Burning urination o o Blood in urine o o Incontinence o o Weak urine stream o o Discharge o o Heavy menstrual bleeding o o Impotence Yes No Psychiatric o o Depression o o Anxiety I personally reviewed all the systems listed above. Signature Date

APPOINTMENT CANCELLATION POLICY MANA Pulmonary Medicine requires a 24-hour notice of cancellation of appointments. Please note there will be a $50.00 fee charged to the patient if the appointment is not cancelled 24-hours prior. If you have an emergency, please let us know and the fee may be waived. I have read and understand this policy. PRINT NAME: D.O.B.: PATIENT SIGNATURE: DATE: HOME PHONE # CELL PHONE #

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