Smyrna Pulmonary and Sleep Associates, PLLC
Smyrna Pulmonary & Sleep Associates
Dr. Prakash Patel
Dr. Vineesha Arelli
13181 Old Nashville Hwy. , Suite 150 1940 N. Jackson Street, Suite 150
Smyrna, TN 37167 Tullahoma, TN 37388
(615) 355-5105 (931) 536-4149
Fax (615) 355-5195 Fax (615) 355-5195
PULMONARY CONSULT PATIENT HISTORY FORM
DATE: ___________
PATIENT NAME: ________________________________________ DOB: _____________________________
REASON FOR VISIT/CHIEF COMPLAINT:
□ SHORTNESS OF BREATH □ COPD □ ASTHMA
□ COUGH □ EMPHYSEMA □ LUNG NODULE
□ OTHER: ______________________________________________________________________________________
Please provide your current medicine list or medication bottles
to the Medical Assistant for our review and to update your chart.
Page 1
Smyrna Pulmonary and Sleep Associates, PLLC
PATIENT NAME: ________________________________________ DOB: _____________________________
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Page 2
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Previous Surgery
Type of Surgery Year Performed
¡% LUNG SURGERY _______________
¡% HEART SURGERY _______________
¡% OTHER _______________
_______________________________________
¡% OTHER ______________
_______□ LUNG SURGERY _______________
□ HEART SURGERY _______________
□ OTHER _______________
_______________________________________
□ OTHER ______________
_______________________________________
Vaccination
□ INFLUENZA
___________________
Date last received
□ PNEUMOCOCCAL
___________________
Date last received
Past Medical History
□ COPD
□ ASTHMA
□ LUNG CANCER
□ HIGH BLOOD PRESSURE
□ HIGH CHOLESTEROL
□ DIABETES
□ HEART DISEASE
□ OTHER: ___________________________
____________________________________________________________________________________
Current Meds
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Drug Allergy
Drug Reaction
• ________________________________
• ________________________________
• ________________________________
• ________________________________
• ________________________________
FOR OFFICE USE ONLY
_____ ENTERED DATA
______ SCANNED
Symptoms
□ FEVER, SWEATS OR CHILLS
□ UNUSUAL FATIGUE
□ LOSS OF APPETITE
□ WEIGHT LOSS MORE THAN 5 LBS
□ HEADACHES
□ EARACHES
□ EYE IRRITATION
□ BLURRED OR DOUBLE VISION
□ SINUS PROBLEMS
□ DRY EYES OR MOUTH
□ SNORING
□ CHEST PAIN
□ IRREGULAR OR RAPID HEART BEAT
□ HEARTBURN/INDIGEESTION
□ DIFFICULTY SWALLOWING
□ NAUSEA OR VOMITING
□ ABDOMINAL PAIN
□ DIARRHEA
□ CONSTIPATION
□ DIFFICULT OR PAINFUL URINATION
□ FREQUENT URINATION
□ IRREGULAR MENSTRAUL
□ PERIODS/BLEEDING
□ SWELLING IN ANKLES
□ JOINT PAIN OR MUSCLE ACHES
□ FINGERS TURN WHITE & PAINFUL IN COLD
□ BACK OR NECK PAIN
□ AUTO ACCIDENT-WHEN?__________________
□ SERIOUS INJURY___________________________
□ DIZZINESS OR FAINTING
□ NUMBNESS OR WEAKNESS
□ ANXIETY
□ DEPRESSION
□ OTHER ____________________________________
Family History
Condition Which Relatives Affected
□ ALLERGIES _________________________
□ ASTHMA _________________________
□ LUNG DISEASE _________________________
□ HEART DISEASE _________________________
□ CANCER _________________________
□ OTHER _________________________
___________________________________________
Social History
Marital Status:
□ SINGLE □ MARRIED □ SEPERATED
□ DIVORCED □ WIDOWED
********************************************************
Are you working now? □ YES □ NO
What is (or was) your occupation: ___________________________________________
********************************************************
Any animals in your home? □ YES □ NO
********************************************************
Alcohol use? □ YES □ NO
If yes, how much? ___________________________
********************************************************
Have you ever smoked cigarettes? □ YES □ NO
How many packs/day? ______________________
How many years? ___________________________
If you quit smoking, when? ___________________
................
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