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DATE:____________ REQUESTINGPHYSICIAN:________________________
NOTE:PleasehelpusfindoutaboutyoubyfillingoutthePatientsideofthisformonpages14.Ifyoudontknowthe
answertooneofthequestions,askyourbedpartnerifhe/shecanansweritforyou.
PLEASELEAVECLINICIANSIDEBLANK.
___________________PATIENT________________________CLINICIAN___________________
Whyareyouheretoseeapulmonary(lung)doctor? CC
_____________________________________
_____________________________________
Checkoffanylungorbreathingproblemsorsymptoms:HPI
___Unabletocatchyourbreath
___Wheezing
___Highbloodpressure
___Heartmurmur
___Unabletosleeplayingflatorwithone(1)pillow
___Nightsweats
___Coughedupblood
___Chestpainsorpressure
___Shortnessofbreath
___Dizziness
___Swollenlegs
___Heartfailure
___Bluelipsorfingernails
___Legcrampswhenyouwalk
Haveyoueverhad:
___Apulmonaryfunctiontestorspirometry
___Apulmonarystresstest
___Abronchoscopyorbronchial/lungbiopsy
___Lungsurgery,includingremovalofalobe
___Anelectrocardiogram
___Heartsurgery
___Lungcancer
___Exposuretotuberculosisorhadtuberculosis
___Pneumonia
___Bloodclot
Areyoubeingtreatednoworhavebeentreatedfor__PPERSONAL,FAMILY,SOCIALHISTORY__
anyillness?Pleaselistthem.
1. __________________________________________PastMedHx
2. __________________________________________
3. __________________________________________
4. __________________________________________
5. __________________________________________
___________________PATIENT________________________CLINICIAN___________________
Haveyoueverhadanyoperations?Anyinjuries? PastSurgHx
1. __________________________________________
2. __________________________________________
3. __________________________________________
4. __________________________________________
5. __________________________________________
Checkifanyclosefamilymember(parents,siblingsandFamilyHx
Children)have:
___Heartproblems
___Diabetes
___Heartburn
___HighBloodPressure
___Cancer
Otherhealthproblems____________________________
________________________________________________
MaritalStatus S M W D SocialHx
Withwhomdoyoulive?____________________________
Whatisyouroccupation?___________________________
Whatareyourleisureactivities?_____________________
Whatisyoureducationlevel?_______________________
Tellusaboutyourriskoflungdisease.__________RRISKFACTORS__________
Pleasecheckifyouhave:
___Workedaroundtoxicchemicalsorsubstances
___Asbestosexposure
___Eversmoked
___Livedwithsomeonewhosmokes
Doyouexercise(includingwalking)?
___Yes___No
Hasaclosefamilymemberhadlungcancer,tubercolusis
oremphysema?
___Yes___No
Ifyes,who?____________________________________
Ifyouareawoman,haveyoupassedmenopause(change
oflife)?___Yes___No
Ifyes,atwhatage?______________________________
Doyoutakeestrogenreplacement?___Yes___No
___________________PATIENT________________________CLINICIAN___________________
Pleasetellusanythingelseaboutyourlungs:
________________________________________________
________________________________________________
Doyousmoke? HealthHabits:
___Yes___No
Ifyes,howmaypacksperday?____________________
Forhowmanyyears?____________________________
Ifyounolongersmoke,whendidyouquit?__________
Howmuchalcoholdoyoudrink?____________________
Doyouuseanyrecreationaldrugs?
___Yes___No
Ifyes,list:_____________________________________
Pleasetellusaboutyourmedicines(names,dosesor__MEDICINES,ALLERGIES,VACCINATIONS_
strength,howmanytimesaday).Includeoverthe
countermedicationsandmedicinethatyouverecently
stoppedtaking:
1. ________________________________________Medicines
2. ________________________________________
3. ________________________________________
4. ________________________________________
5. ________________________________________
6. ________________________________________
7. ________________________________________
8. ________________________________________
9. ________________________________________
10. ________________________________________
11. ________________________________________
12. ________________________________________
13. ________________________________________
14. ________________________________________
15. ________________________________________
Areyouallergictoanymedication:Allergies
___Yes___No
Ifyes,listmedicationstowhichyouareallergic&reactions:
1. _________________________________________
2. _________________________________________
3. _________________________________________
4. _________________________________________
5. _________________________________________
___________________PATIENT________________________CLINICIAN___________________
Doyouhavehayfever?
___Yes___No
Ifyes,whatkindofsymptomsdoyouexperience?
______________________________________________
______________________________________________
Haveyouhadthefollowingvaccinations?Vaccinations
___Influenza(FluShot)annually
___Pneumococcal(Pneumonia)Vaccine
Pleasecircleanysymptomyouhave,sowecanfindmoreaboutit:REVIEWOFSYMPTOMS__
Lackofenergy;daytimesleepiness,troublesleeping;Constitutional
Snoring;lossofappetite;weightchanges;fevers
Eyeproblems,suchasdoubleorblurredvision;glaucoma;HEENT
cataracts
Hearingproblems;buzzingorringinginears
Allergies;hayfever
Sinusproblems
Bloodpressureorheartproblems Cardiac
Asthma;tuberculosis Pulmonary
Stomachproblems;heartburn;indigestion;Gastrointestinal
changeinbowelhabits
Urinaryproblems;frequency,infections;stones;bladderGenitoUrinary
Men:Prostateproblems;nighttimeurination
Women:Abnormalmenstrualperiods;breastlumps;FemaleReproductive
couldyoubepregnant;recentmammogram,papsmear
orpelvicexam
Jointpains,swellingorredness;arthritis;backpainMusculoskeletal
Muscleachesortenderness;gout
Rash,itchingorotherskinproblemsDermatologic
Paralysis(eventemporary);numbness;lossofbalance;Neurologic
Seizures;lossofmemory;headaches;stroke;
Unusualthoughts;nervousness;cryingorsadness;Psychiatric
Suicideattempts;depression
Thyroiddisorder;diabetes;excessthirstorhunger;Endocrinologic
Frequenturination
Bleeding;easybruising;riskfactorsforHIV;anemia;cancerHematologic
Others:__________________________________________
Personallyreviewedbyme.Iagreewithorhaveamendeditsfindings.
____________________________________________
PhysicianSignature
___________________PHYSICALEXAMINATION________________
GENERALAPPEARANCE_________________________________________________________________
N=NormalA=AbnormalD=DeferredDescriptionofAbnormalFindings
1) NOSE:Mucosa_____Turbinates_____Septum
2) MOUTH:Mucosa_____Teeth_____Gums_____
Tongue_____Pallate:Hard_____Soft_____
Tonsils_____PosteriorPharynx_____
3) NECK:Appearance_____Symmetry_____
TrachealPosition_____Crepitus_____
Thyroid_____JVD_____
4) RESPIRATORY:Inspect_____Symmetry_____
Percussion_____Palpation_____
Auscultation_____Effort_____
5) HEART:Apex_____Heave_____Thrill_____
Sounds_____Murmur_____Rub_____
6) ABDOMEN:Masses_____Tenderness_____
Liver_____Spleen_____BowelSounds_____
7) LYMPH:Neck_____Axilla_____Groin_____
Other(Specify)_____
8) MUSCULOSKELETAL/NEUROLOGIC:Gait_____
Station_____Strength_____Atrophy_____
Tone_____AbnormalMovement_____
9) EXTREMETIES:Varicosities_____Edema_____
Pulses_____Temp_____Tenderness_____
Digits_____Nails_____
10) SKIN:Scars_____Rashes_____
Describe___________________
11) NEUROPSYCH:Oriented_____Mood_____
NewPatient OfficeConsult
99201 15BulletPoints 99241
99202 611BulletPoints 99242
99203 1217BulletPoints 99243
99204AllItemswithGrayBorderand1 99244
99205ItemineachnonGrayBorder99245
___________________MEDICALDECISIONMAKING______________
DATAREVIEWED:
Lab(Date)
Hemoglobin___________
Electrolytes___________
Other(Specify)_________
PulmonaryFunctionTest(Date)________________________________________________
Bronchoscopy(Date)_________________________________________________________
Other(List/Date)____________________________________________________________
XRays(Date) PhysicianInterpretation:
__________Chest
__________CTChest
__________MRI
__________Other(ListType)
IMPRESSION:
PLAN: F/U___________
___PFT/Spirometry___
___V/QScan___
___ChestXray___
___NocturnalPulseOximetry
___Bronchoscopy
___Lab
___PulmRiskReduction
___CPEXLevel1___Level2___
Other_________________________
________________________________________________
PhysicianSignature