Patient Intake Questionnaire



PULMONARY AND SLEEP PHYSICIANS OF HOUSTON, P.A.

501 ORCHARD, SUITE 200. WEBSTER, TX. 77598 TEL.: 281-557-8555 FAX: 281-554-3657

Niranjan Iyer, M.D. Alfred Maksoud, M.D. F. Adam Kawley S. Hyder Jaffery, M.D.

Patient Intake Questionnaire

NAME ___________________________________________________ AGE ________ DATE ______________

Referring Physician ___________________________________________ Office # (______) ________________

PAST ILLNESSES: (Check all that apply)

( Abnormal heart beat ( Angina/Chest pain

( Asthma ( Allergies/Hay Fever

( Arthritis ( Blood Clots

( Blood Problem ( Chronic Sinus Problems

( Chronic obstructive pulmonary

disease/ Emphysema

( Cancer (site ____________________)

Previous treatment:

( Surgery ( Radiation ( Chemotherapy

( Diabetes ( Eye problems

( Heartburn/GERD ( Heart Attack

( Hiatal Hernia ( High Blood Pressure

( Heart Failure ( Liver Problem

( Kidney Problem ( Pulmonary Fibrosis

( Pneumonia ( Skin Problems

( Sarcoidosis ( Stroke

( Stomach Ulcer ( Tuberculosis

( Thyroid Problems

( Weight Loss Medication use

( Fracture ( site_______________)

Have you had any serious illness? Yes No

Have you ever been hospitalized or under

medical care for very long? Yes No

If Yes, for what reason?

______________________________________

______________________________________

OPERATIONS: (Check all that apply)

( Appendectomy ( Gallbladder

( Heart Bypass Surgery ( Heart Valve Surgery

( Hysterectomy ( Joint Replacement

( Lung Surgery ( Vascular Surgery

( Mastectomy ( Inguinal Hernia Repair

( Other _______________________________________

SOCIAL HISTORY:

Tobacco:

( Never Smoked ( Active Smoker

( Ex-Smoker Quit______Years Ago

Years Smoked_______

Packs per Day Smoked______

Recreational Drug Use? Yes No

Alcoholic Beverages:

( Never ( Less than 1 per week

( 1-5 per week ( Other_____________

Major Hobbies: _______________________________________

______________________________________

Foreign travel in last year__________________

US travel in last year _____________________

Do you have any pets? Yes No

Type________________ How Many________

OCCUPATIONAL HISTORY:

Employment:

( Full time ( Part Time ( Retired

List major jobs you held throughout your life: _______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

Have you ever worked with asbestos? Yes No

Exposed to fumes, Dust or Solvents? Yes No

Patient Intake Questionnaire

How much time have you lost from work because

of breathing problems during the past…?

Six Months_______ One Year_______

Five Years________

SLEEP HISTORY:

Do you sleep all night? Yes/No

Do you snore? Yes/No

Do you have a bed partner? Yes/No

Have you been told that you stop

breathing while asleep? Yes/No

Do you wake up tired after sleeping? Yes/No

Do you fall asleep easily watching TV? Yes/No

Do you fall asleep at work? Yes/No

Have you fallen asleep at the wheel? Yes/No

Do you have nightmares? Yes/No

Do you feel confused upon awakening Yes/No

Do you grind your teeth at night? Yes/No

Do you kick/ twitch your legs at night? Yes/No

Do you feel paralyzed upon falling

asleep or upon awakening? Yes/No

Are you a student? Yes/No

|Family |Age |Health |Age at Death (If |Major Health Problems |

|Member | | |Deceased) | |

|Father | | | | |

|Mother | | | | |

|Brother/Sister | | | | |

| | | | | |

| | | | | |

FAMILY HISTORY:

Have either parent, brother, sister, or grandparent ever had? (Check all that apply)

( Stroke ( Heart Trouble ( Diabetes ( Bleeding Tendency

( Asthma ( COPD/Emphysema ( High Blood Pressure ( Tuberculosis

( Cancer ( Sarcoidosis ( Pulmonary Fibrosis

MOST RECENT VACCINATIONS:

Flu Vaccine ____________ (Date)

Pneumonia _____________ (Date)

Patient Intake Questionnaire

LIST CURRENT MEDICATIONS (Including Herbs and over the counter medications/ supplements)

|Medications |Dose |How Often |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

**If list is longer than boxes provided, continue list on back of this form**

Do you use mineral oil, mineral oil nasal drops, or petroleum products? Yes No

PLEASE LIST ANY MEDICINE/FOOD/ENVIRONMENTAL ALLERGIES:

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Patient Intake Questionnaire

CHECK ALL THAT APPLY

SYSTEMIC/CONSTITUTIONAL:

( Fevers ( Chills (bed shaking)

( Night Sweats ( Weakness

( Recent weight change

( Loss_______Lbs. ( Gain_______Lbs.

Energy Level

( Excellent ( Good

( Fair ( Poor

HEENT:

( Blurry Vision ( Wear Glasses

( Dry Eyes ( Runny Nose

( Sinus Congestion ( Chronic Sinus Problems ( Post Nasal Drip ( Allergy Symptoms

( Hoarseness

NEURO-PSYCHIATRIC:

( Trouble Hearing ( Fainting Spells

( Convulsions or Seizures ( Headaches

( Change in mood ( Paralysis

( Coordination Problems ( Depression

( Anxiety

NECK:

( Stiffness ( Swelling or Masses

LUNGS:

( Asthma or Wheezing ( Cough

( Coughing blood ( Difficulty Breathing

( Pain with deep breathing ( Pleurisy

( Sarcoidosis

( Shortness of breath at rest

( Shortness of breath with activity

How much activity? ____________________

( Shortness of breath climbing more than 1 flight of stairs

( Other Lung Problems

Define your lung problems _______________

_______________________________________

_______________________________________

HEART:

( Chest Pain, Pressure or Tightness

( Shortness of breath lying down

( Shortness of breath that awakes you from sleep

( Palpitations

( Difficulty walking more than 2 blocks

( Swelling of feet or ankles

( Heart murmur

GASTROINTESTINAL:

( Pain with swallowing

( Difficulty swallowing

( Does food get stuck in your throat?

( Change in appetite ( Hepatitis

( Jaundice ( Blood in stool

( Change in bowel habits

( Frequent Diarrhea ( Constipation

( Heartburn or Indigestion

( Pain in abdomen

URINARY:

( Loss of urine ( Difficulty Urinating

( Pain Urinating ( Blood in Urine

( Kidney Trouble

HORMONAL:

( Excessive Thirst ( Excessive Urination

( Diabetes ( Thyroid Problems

( Heat or Cold intolerance

MUSCLES AND BONES:

( Arthritis Symptoms

( Joint Pain or Swelling

( Weakness of muscles

( Difficulty walking

SKIN:

( Skin Disease ( New Rash

( Jaundice ( Eczema

LYMPH GLANDS/BLOOD:

( Enlarged Glands ( Easy Bruising

( Easy Bleeding

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download