PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

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Transcription:

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your reason for visiting the doctor today? 2. When did you first notice this problem? 3. What do you expect to gain from today s visit? 4. Do you have any of the following? (Please check yes or no. If yes, please explain.) a) Shortness of breath No Yes b) Wheezing No Yes c) Hay Fever (Allergies) No Yes d) Cough No Yes e) Cough up phlegm No Yes f) Coughing up blood No Yes g) Fevers No Yes h) Recent weight change No Yes i) Sleeping disorder No Yes j) Difficulty swallowing No Yes k) Chest Pain No Yes l) Chest tightness No Yes 5. Do you smoke? Yes No How long? (years) Packs per day? 6. Have you ever smoked? Yes No How long? (years) When did you quit? If yes, how much did you smoke? 7. Have you ever been given: Date Location / Where a) Pneumonia vaccine b) Flu vaccine

8. Have you ever been diagnosed with any of the following? (Please check yes or no.) Asthma No Yes Bronchitis No Yes Allergies No Yes Blood Disorders No Yes Sinusitis No Yes Pulmonary Hypertension No Yes Sleep Apnea No Yes Emphysema No Yes Lung Cancer No Yes Pleurisy No Yes Pneumonia No Yes Pneumothorax No Yes Pulmonary Emboli No Yes Pulmonary Fibrosis No Yes Bronchiectasis No Yes Cancer No Yes Colitis No Yes Diabetes No Yes Hypertension No Yes Heart Disease No Yes Seizures No Yes Irregular Heart Rate No Yes Thyroid Problems No Yes Stomach Ulcers No Yes Arthritis No Yes Kidney Disease No Yes Other Liver Disease No Yes If you answered yes above, please explain. 9. Please list all previous surgeries and hospitalizations: Date Surgery Type/ Reason for Hospitalization Location Surgeon/Attending Physician 10: List any other medical illnesses:

REVIEW OF SYSTEMS: (Please check yes or no.) Constitutional: Eyes: Fatigue No Yes Need for glasses No Yes Fever No Yes Blurred vision No Yes Night sweats No Yes Double vision No Yes Weight loss No Yes Loss of vision No Yes Weight gain No Yes Pulmonary: Cardiac: Shortness of breath No Yes Chest pain No Yes Wheezing No Yes Palpitations No Yes Cough No Yes Leg swelling No Yes Ear, Nose, and Throat: Gastrointestinal: Sore throat No Yes Heartburn No Yes Ear ringing No Yes Diarrhea No Yes Decreased hearing No Yes Constipation No Yes Dental problems No Yes Blood in stool No Yes Oral lesions No Yes Hemorrhoids No Yes Difficulty swallowing No Yes Loss of appetite No Yes Hoarseness No Yes Reflux / GERD No Yes Musculoskeletal: Renal: Back problems No Yes Pain/Burning urination No Yes Joint swelling No Yes Frequent urination No Yes Joint pain No Yes Nocturnal frequency No Yes Skin & Breast: Neurological: Skin lesions No Yes Dizziness No Yes Rashes No Yes Lethargy No Yes Breast masses No Yes Passing out No Yes Discharge No Yes Weakness No Yes Difficulty speaking No Yes Psychiatric: Seizures No Yes Depression No Yes Anxiety No Yes Endocrine Enlarged thyroid No Yes Sleep-Related Symptoms: Thyroid nodules No Yes Snoring No Yes Thirst No Yes Sleepy during daytime No Yes Heat/cold intolerance No Yes Restless sleep No Yes Difficulty sleeping No Yes Daytime fatigue/tired No Yes

SOCIAL HISTORY 1. Marital Status: Married Single Divorced Widowed 2. Number of Children 3. Alcohol Intake Yes No How much? How often? 4. Recreational Drugs Yes No 5. Dwelling: Carpet Yes No Central A/C Yes No Pets Yes No What kind? How many? EXPOSURE HISTORY 1. Where were you born? 2. Where were you raised? 3. Occupation Present/Past 4. Hobbies: 5. Have you ever worked with or around the following (if so, please explain): a. Indoor smoking environment b. Asbestos e. Mining c. Welding f. Animals d. Soldering g. Inhalants FAMILY HISTORY Have any members of your family ever had (please check): Disease Relationship 1. Diabetes 2. Lung Cancer 3. Cancer 4. High Blood Pressure 5. Emphysema 6. Asthma 7. Kidney Disease 8. Sleep Apnea

MEDICATION INFORMATION 1. List all medication allergies and type of reaction: 2. List all current medications: Medication Dosage Frequency Prescriber *Please use the back of this form if needed

Medications continued: Medication Dosage Frequency Prescriber

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