DESERT CENTER FOR ALLERGY AND CHEST DISEASES HEALTH QUESTIONAIRE NAME. PAST MEDICAL PROBLEMS- Check mark if you have any of the following

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DESERT CENTER FOR ALLERGY AND CHEST DISEASES Pulmonary Medicine, Allergy/Immunology, Sleep Disorders Pulmonary Rehabilitation, Pulmonary Function Laboratory HEALTH QUESTIONAIRE NAME What is your presenting problem? How long has it been going on? PAST MEDICAL PROBLEMS- Check mark if you have any of the following Heart problems Liver problems Stroke Arthritis Emphysema Glaucoma Bronchitis Brittle bones Asthma Cancer Stomach ulcers High Blood pressure Thyroid disease Diabetes

Major surgeries? Allergies to any medications? List of medications? SOCIAL HISTORY Have you ever smoked? What age did you begin? How many packs a day? Are you currently a smoker? How often do you drink alcohol? How many? Are you married? How long? Is someone living with you? How long? Do you have any children? How many? Do they live in Arizona? How long have you lived in Arizona? What kind of work do/did you do? What is your spouse s occupation? Do you have pets? What kind? Have you traveled in the past year outside of the southwest? Where?

FAMILY HISTORY What illnesses are seen in your family? Asthma, Emphysema, Cancer, Tuberculosis, Heart Disease or Heart Attacks, High Blood Pressure, Strokes, or Diabetes. Father: Mother: Siblings: Children:

REVIEW OF SYSTEMS Have you had any fever or illnesses in the past 6 months? How is your appetite? Any recent changes? Has your weight changed in the last 6 months? Do you have any rashes? Any recent changes in vision? Do you have difficulty hearing? Do you have postnasal drip? Do you have a history of sinus problems? Do you have neck or pain lumps? Do you have a history of Valley Fever? Have you ever been tested for Tuberculosis? Is so, where and when? Do you have chest pain or pressure with exertion? Have you had any fainting spells? Do your legs swell? Do you get heart burn? Has there been a recent change in bowel habits? Do you have any pain or blood with urination? Do you have urinary incontinence? Do you have redness, swelling or warmth of your joints? Do you have new or recent headaches?

DAYTIME SLEEPINESS YES NO Are you usually sleepy during the day? Do you usually have trouble staying awake during the day? Have you ever fallen asleep at an inappropriate time like (talking, eating, working, or driving)? SLEEP SYSTEMS Does your mate sleep in the same room (due to sleep habits)? Have you been told you stop breathing during sleep? Are you a violent sleeper (thrash around, throw off sheets)? Do you grind your teeth at night? Do you awaken with headaches in the a.m.? Do you awaken with chest pain? Do you awaken with shortness of breath? Do you experience fogginess or incoordination upon wakening? Sinus problems? Family history of snoring/disturbed sleep? NARCOPLEPSY SYMPTOMS Persistent, uncontrollable sleep attacks? Automatic behavior? (Perform routine activities without remembering) Hypnagogic hallucination? (Vivid hallucination while falling asleep) Sleep paralysis? (Inability to move while Partially awake)

Surgery on tonsils Adenoids Deviated septum Broken nose Obstruction Comments: Epworth Sleepiness Scale Rate the chance that you will doze off or fall asleep during the following routine daytime situations. Sitting and reading Watching T.V. 0- Would never doze 1- Slight chance of dozing 2- Moderate chance of dozing 3- High chance of dozing Sitting inactive in a public place (Ex. Theater or meeting) As a passenger in a car for an hour without a break. Lying down to rest in the afternoon Sitting and talking to someone In a car, while stopped in traffic Sitting quietly after lunch (When you ve had no alcohol)

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