QUESTIONAIRE—CHRONIC COUGH AND LARYNGOSPASM
[pic]
CHRONIC COUGH, LARYNGOSPASM, NEURALGIA
NAME: ____________________________________ DATE: _________________________
DATE of BIRTH: ____________AGE: _________ OCCUPATION: ____________________
WHO REFERRED YOU TO THIS OFFICE? FRIEND________PHYSICIAN_______OTHER___
WOULD YOU LIKE A REPORT SENT TO YOUR PHYSICIAN REGARDING TODAY’S VISIT?
IF YES, PLEASE LIST: PHYSICIAN NAME___________________________________________
ADDRESS____________________________________________________
Street City State Zip
1) When did your coughing or laryngospasm problem begin? (number of months or years): _______________________________________________________________________
2) At the beginning, what did it seem started the cough or laryngospasm? Please circle all that apply:
-upper respiratory infection -bronchitis or pneumonia
-surgery on my neck -surgery on my chest -other____________________
3) Do you experience any warning sensation just before coughing or laryngospasm begins? Yes No If yes, please circle any that apply:
-Sudden tickle -Sudden “dry patch” -Sudden burning -A jabbing or stabbing sensation
-A feeling of a “crumb caught in my throat” -Other: ___________________
LOCATION: _____________________________________
4) Are you aware of anything that triggers coughing / laryngospasm? Yes No
If yes, please circle all that apply:
-Talking -Laughing -Singing
-Breathing cold air -Breathing warm air -Touching a spot on my neck
-Eating -Swallowing -Posture change esp. at night
-Other___________________
…please underline the main trigger in the above list, if any
5) Please review the list of things that we’ve learned may happen to persons with severe coughing or laryngospasm. Please circle all that apply:
-I turn red -My eyes tear -My nose runs
-I almost throw up -I do throw up -I nearly pass out -I do pass out
-I have sudden intense difficulty breathing (laryngospasm)
-I lose urine -I have broken one or more ribs
-Other:______________________________
6) Estimated duration of a “major attack”: ________ # during day _____# during Sleep____
7) Estimated duration of a “lesser attack”: ________ # during day _____ # during Sleep____
8) On average, how many times do you experience laryngospasm? Day_____Night_____
NAME: _________________________________________
9) Most people with your problem say it is roughly the same week after week. Some, however, notice periods of greater or lesser severity. Which is the case for you? Please circle one of the following.
-Roughly the same since onset -Varies from week to week
-Varies from month to month -May have long periods relatively symptom free
10) If your cough / laryngospasm varies, is there any discernible pattern? Circle any that
apply.
-Worse for some time following upper respiratory infection
-Seems to be tied to the change of seasons
-Other __________________________________________
11) How many doctors do you think you have seen specifically for this problem? _________
12) How many in each of the following specialties? Please circle all that apply.
-Family Doctor _____ -Internist ____ -Pulmonologist _____ -Ear, Nose, Throat ___
-Psychiatrist _____ -Allergist ____ -Speech Pathologist
-Other ___________________________________________
13) What tests have you had for your problem? Please circle all that apply.
-Chest xray -CT scan -MRI -Pulmonary Function Tests
-Bronchoscopy -24-hour acid test -Esophagoscopy -Allergy tests
Were they all normal? Yes No
14) What are you told is the cause of your cough / laryngospasm? _______________________
15) Please indicate these medications you have tried, by name or type. Please circle or fill in as appropriate.
Asthma inhalers ________________ Acid reflux medication ____________________
Cough suppressant ______________ Antibiotics_____________________________
Expectorant ___________________ Topical anesthetic _______________________
Amitriptyline (Elavil) Gabapentin (Neurontin)
Oxcarbazepine (Trileptal) Other 1 __________________________
Other 2_________________________ Other 3 __________________________
16) Did any medication ever seem to help noticeably? Yes No If yes, which one(s)?
Medication: ___________________________ % reduction symptoms: _____________
Medication: ___________________________ % reduction symptoms: _____________
NAME: _________________________________________________________________________
17) Have you tried any other treatments for your problem? Yes No If yes, please circle any that apply.
Hypnosis Accupuncture Herbal remedies
Vitamins Other _________________________________
18) Did any of the above alternative treatments seem to help? Yes No
If yes, which one(s)?
19) Are you on currently or have you ever taken an ACE inhibitor generally used for blood
pressure control? Yes No If yes, please circle any that apply—the first list is
trade names, second is chemical name.
Accupril Aceon Altace Capoten
Lotensin Mavik Monopril Prinivil
Univasc Vasotec Zestril
Benazepril Captopril Cilazapril Enalapril
Enalaprilat Fosinopril Lisinopril Moexipril
Perindopril Quinapril Ramipril Trandolapril
20) In what ways has this problem affected you? Please circle all that apply.
a. It hasn’t—I just carry on and cope.
b. I limit talking.
c. I avoid public events when possible, for fear of making a disturbance with my coughing.
d. I sleep alone so as not to disturb my bed partner.
e. I have lost my job because of the coughing.
f. I’ve had to change jobs because of my coughing.
g. Other: _________________________________________________
21) On a scale of 1 to 7, where 1 represents a minor annoyance, 4 a medium, somewhat
difficult, but not terrible problem, and 7 a major problem that is “ruining your life,” how
would you rate your problem?
1 2 3 4 5 6 7
22) Is there anything else you would like to say about your problem?
PAST MEDICAL HISTORY
23) The following is a list of medical problems. Please circle any that apply, and describe.
High blood pressure _____________________ Heart disease _______________________
Diabetes _______________________________ Lung problems _____________________
Kidney disorders ______________________ Neurological problems _________________
NAME ____________________________________________________________________________
24) From the following list of types of surgeries: Please circle those that apply, and describe in the blanks.
Ear, Nose, Throat ______________________________________________
Chest ________________________________________________________
Abdomen _____________________________________________________
Orthopedic ____________________________________________________
Neurological ___________________________________________________
Other _________________________________________________________
25) Do you smoke? Yes No If yes, how many years? _______________
26) If you don’t smoke now, did you ever smoke? Yes No Years? __________
27) Alcohol consumption. Circle one. -daily -weekly -monthly -rarely -none
28) Please list the medications you are currently taking:
Medication: __________________________ Medication: _______________________
Medication: __________________________ Medication: _______________________
Medication: __________________________ Medication: _______________________
Medication: __________________________ Medication: _______________________
29) Please list any medications to which you are allergic: _____________________________
REVIEW OF SYSTEMS Please circle any of the following symptoms that apply.
Weight loss Fever/chills Hearing difficulty Vision disturbance
Breathing problem Chest pain Irregular heartbeat Dizziness
Nausea /vomiting Heartburn Acid belching Morning sore throat
Hoarseness Morning mucus Snoring Nighttime breathholding
Cold intolerance Arthritis Numbness or tingling Weakness
Skin problem Other: ________________________
FAMILY HISTORY Please fill in which family members have the following disorders.
Heart disease___________________________________________________________
Asthma _______________________________________________________________
Acid reflux or GERD ___________________________________________________
Coughing problem _____________________________________________________
Diabetes ______________________________________________________________
Cancer (specify type) ___________________________________________________
Neurological disorder __________________________________________________
Psychiatric disorder ___________________________________________________
Other _______________________________________________________________
______________________________________________________________
______________________________________________________________
END OF QUESTIONNAIRE—PLEASE STOP HERE
NAME: _____________________________________________________________________
EXAMINATION:
General: WDWN Distinguishing issues: _________________________________________
OC nl abnl ______________________________________________________
OP nl abnl ___________________________________________________________
HP nl abnl ___________________________________________________________
LX: nl abnl ___________________________ Inadequate visualization
Trachea: nl abnl ___________________________ Inadequate visualization
Lungs: nl abnl ___________________________________________________________
Procedure: Videoendoscopy Videostroboscopy Bronchoscopy VESS
Anesthesia: 2% Pontocaine to nose
Hurricaine to Oral Cavity, Oropharynx
4% lidocaine to larynx, trachea via Abraham Cannula
4% lidocaine via cricothyroid membrane puncture for tracheal anesthesia
4% lidocaine via existing tracheotomy tube
Sedation: no yes _____________________________________________________________
Scope: ENF-V videoendoscope
Wolf 90-degree telescope
PEF-V esophagoscope
Findings: normal abnormal
Abnormal : quivering asymmetry myoclonus hyperadduction phon.
Hyperadduction breathing tremor
Reflux findings mucosal disturbance ____________________
Other____________________________________________________
Impression: neuropathic cough nonorganic cough Drug-induced cough ________
Bronchitis Asthma-related Reflux cofactor
Plan: Reassurance only Speech Therapy Reflux med _______________
Asthma inhaler __________________________
Amitriptyline _______________________________________________________
Neurontin __________________________________________________________
Trileptal ___________________________________________________________
Followup: Phone to Physician Voicemail 1 week & F/U appt. 1 month
LETTER:
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- gerd central texas allergy asthma
- questionaire—chronic cough and laryngospasm
- urinary leakage and prolpase family care medical group
- office of the vice chancellor for research washington
- advice for those with voice and throat symptoms
- n703 chronic soap note
- invoice centers for disease control and prevention