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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