New Clinic Visit Pulmonary Medicine Patient form Page 1



New Clinic Visit Pulmonary medicine Page 1

Please answer the following questions to help doctor evaluate you.

Your name: __________________________________ Date: ______________

I Chief complaint: _____________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

|Past medical history (circle and describe) |Previous surgery (circle, describe and indicate year) |

| |year |

|COPD |Lung surgery _____________ |

| | |

|Asthma |Heart surgery ______________ |

| | |

|Lung cancer |Other (List) |

| | |

|High Blood Pressure |____________________________ |

| |____________________________ |

|High Cholesterol |____________________________ |

| | |

|Diabetes |Vaccination: |

| | |

|Heart Diseases |Last Influenza Vaccine ______________ |

| | |

|Others (list): |Last Pneumococcal Vaccine __________ |

|__________________________ | |

|__________________________ | |

|__________________________ | |

|__________________________ | |

New Clinic Visit Pulmonary medicine Page 2

| Current med lists:( with doses) |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

|__________________________________________ |

| |

|Drug allergy - Type of reaction |

|__________ ____________________ |

|__________ _____________________ |

|__________ _____________________ |

II Your family History III Your Social History

|What diseases run in your family? |Marital status:  single  Married  Separated  Divorced  Widowed |

|(circle, describe and indicate relatives) | |

|Relatives |Are you working now? Yes No (circle) |

|Allergies |What is (or was) your occupation? __________________ |

| | |

|Asthma |Exposure to asbestos or dust or strong fumes at work? Yes No (circle, describe) |

| | |

|Other lung diseases |Have you ever smoked cigarettes Yes No |

| |How many pck/day ________________ |

|Heart Diseases |How many years __________________ |

| |If quit, when______________________ |

|Cancer | |

| |Do you keep animals at home? Yes No ______________ |

|Others (list) | |

| |Alcohol use yes no How much _________________ |

New Clinic Visit Pulmonary medicine Page 3

IV. Symptoms other than chief complaint  Remainder of systems negative

|Please circle and describe problems you have experienced in the | Diarrhea |

|past three months | |

| |Constipation |

|Fever, sweats or chills | |

| |Difficult or painful urination |

|Unusual fatigue | |

| |Frequent urination |

|Loss of appetite | |

| |Irregular menstrual periods or bleeding |

|Weight loss more than 5 lbs | |

| |Swelling in ankles |

|Headaches | |

| |Joint pain or muscle aches |

|Ear aches | |

| |Fingers turn white and painful in cold |

|Eye irritation | |

| |Back or neck pain |

|Blurred or double vision | |

| |Automobile accident or other serious injury |

|Nose or sinus problems, including hay fever | |

| |Unusual dizziness, faintness or loss of consciousness |

|Dry eyes or dry mouth | |

| |Numbness or weakness of part of body |

|Snoring | |

| |Anxiety |

|Chest pain | |

| |Depression |

|Irregular or rapid heart beats | |

| |Other symptoms (List) |

|Heartburn or Indigestion | |

| | |

|Difficulty swallowing or regurgitation | |

| | |

|Nausea or vomiting | |

| | |

|Abdominal pain | |

Assessment: 1) ________________________ Plan: 1) __________________

2) _________________________ 2) __________________

3) _________________________ 3) _________________

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