Name:__________________
Date of Visit: __________________
New Patient Form
Reason for Visit:
□ Abnormal Chest X-Ray
□ ABPA
□ Asthma
□ Asbestosis
□ Chest Congestion
□ Chest Pain
□ Chronic Cough
□ COPD
□ Fatigue
□ Hemoptysis
□ Hypoxia
□ Lung Mass/Cancer
(circle)
(Expose to Asbestos)
□ Pulmonary Hypertension
□ Rhinitis
□ Shortness of Breath
□ Pneumonia
Type _____________
□ Sleep Apnea
□ Snoring
□ Tuberculosis
□ Smoking Cessation
□ Pleurisy
□ Bronchitis
□ Cystic Fibrosis
□ Nose Bleed
□ Carcinoid
□ Emphysema
□ Occupational Lung Disease
□ Cataplexy
□ Emphysematous Bleb
□ Pleural Effusion
□ Hypertension
□ Hyperlipidemia
□ Gastroesophogeal Reflux
□ Depression
□ Restless Leg Syndrome □ Sarcoidosis
Condition(s) Not Presented:
_____________________________________________________________________________________
Is this a Follow Up After: □ Hospitalization □ Lab Test □ Diagnostic Procedure (X-Ray, CT Can, etc)
Is this a Pre-Op Visit? □ Yes □ No If yes what procedure? _______________________________________
Past Medical History:
□ Abnormal Chest X-Ray □ Chest Congestion
□ Hypothyroidism
□ ABPA
□ Chest Pain
□ Asthma
□ Chronic Cough
□ Hypertrophy of
Prostate (Enlarged)
□ Hypoxia
□ Asbestosis
□ Depression
(Expose to Asbestos)
□ Irritable Bowel
Syndrome
□ Interstial Lung Disease
□ Lung Mass/Cancer
□ Pneumonia
Type _____________
□ Positive Skin Test for
Tuberculosis
□ Restless Leg
Syndrome
□ Rhinitis
□ Anxiety
□ Arthritis-Rheumatoid
□ Diabetes
□ Embolism-Pulmonary
□ Sarcoidosis
□ Seizure Disorder
□ Atherosclerosis
□ Bronchitis (Acute)
□ Bronchiectasis
□ Carcinoid (Cancer)
□ Cardiomyopathy
□ Cataplexy
□ Emphysema
□ Emphysematous Bleb
□ Fatigue
□ Gastroesophogeal Reflux
□ Hepatitis
□ Hiatal Hernia
□ Multiple Sclerosis
□ Nyocardial Infarction
□ Nose Bleed
□ Occupational LungDisease
□ Obesity
□ Osteoporosis
□ Congestive Heart
Failure
□ COPD (Chronic
Bronchitis)
□ Cystic Fibrosis
□ Hypertension
□ Pulmonday Hypertension
□ Shortness of Breath
□ Sinusitus
□ Smoking Cessation
□ Snoring
□ Sleep Apnea-Central
□ Sleep ApneaObstructive
□ Insomnia
□ Hemoptysis
□ Pleurisy
□ Narcolepsy
□ Hyperlipidemia
□ Pleural Effusion
□ Tuberculosis
(circle)
Name:__________________
Date of Visit: __________________
Allergy History:
□ No Known Allergies □ No Known Drug Allergies □ Allergy History Unknown
□ Have had an “Allergic Reaction”, but do not know cause?
Reaction Experienced: __________________________________________________________________
Medication Allergies:
□ ACE Inhibitors
□ Aminoglycosides
□ Barbiturates
□ Cephalosporin
□ Erythromycins
□ Iodine (Contrast)
□ Penicillin
□ Other: ___________
□ Other: ___________
Food Allergies:
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
Reaction:______________
□ Acetaminophen
Reaction:_____________
□ Aspirin (Salicylates)
Reaction:____________
□ Benzodiazepines
Reaction:____________
□ Codeine (Derivatives) Reaction:____________
□ Morphine (Derivatives) Reaction:____________
□ Anesthetics
Reaction:____________
□ Zithromax
Reaction:____________
□ Other: ____________ Reaction:____________
□ Other: ____________ Reaction:____________
□ Food:____________ Reaction:______________
□ Food:____________ Reaction:______________
□ Food:____________ Reaction:______________
Environmental:
□ Food:____________ Reaction:______________
□ Food:____________ Reaction:______________
□ Food:____________ Reaction:______________
□Mold
Reaction:______________
□Dust
Reaction:______________
□ Other: ___________ Reaction:______________
□ Other: ___________ Reaction:______________
□ Pollen
Reaction:______________
□ Insect Bite(_______) Reaction:______________
□ Other: ___________ Reaction:______________
□ Other: ___________ Reaction:______________
Family History:
□ No known Pertinent
□ Apnea
□ Bleeding Disorder
□ CHF
□ CVA
□ Diabetes
□ Goiter
□ Hypercholesterolemia
□ Insomnia
□ Myocardial Infarction
□ Pulmonary Fibrosis
□ Restless Leg Syndrome
□ Suicide
□ TIA
Family History
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
□ Asthma
□ Cancer: ___________
□ Coronary Heart Disease
□ Depression
□ Emphysema
□ Heart Disease
□ Hypertension
□ Kidney Disease
□ Narcolepsy
□ Respiratory Condition
□ Seizure disorder
□ Thyroid problems
□ Tuberculosis
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Family Member:________
Name:__________________
Date of Visit: __________________
Social History:
Are you at risk for HIV? □ Yes □ No
If yes, what are your risk factors?
□ Unprotected Sex
□ Caregiver of HIV Pos. Individual(s)
□ Injection Drug User
□ Transfusion Recipient
□ Occupation
□ Other: __________________
Are you currently employed? □ Yes □ No
□ Disabled
□ Disabled due to HIV □ Disabled due to non-HIV condition
□ Part Time
□ Retired
□ Self Employed
□ Unemployed not looking for work
□ Full Time
□ Unemployed Looking for Work
□ Other
Primary Occupation? ___________________________________________________________________
Marital Status:
□ Single
□ Married
□ Divorced
□ Widowed
Do you Exercise: ___Yes ____ Hours Day _______ Day(s) Weekly
___No Exercise Daily
Sleeping Habits: ________ Hours Nightly on Average
Alcohol Use:
□ Do Not Drink
□ Quit Drinking (When?)
Tobacco Use:
□ Occasional Use
□ Moderate Use
□ Heavy Use
(1-8 beverages x monthly) (2-10 beverages weekly) (6+ beverages daily)
Date: _______________
□ Never Smoked
□ Smoke ( ___ pks daily)
□ Smoke (non-cigarette)
Type: ______________
□ Chewing Tobacco
□ Quit Smoking
When did you quit?
How many years
previously smoked? ____
When you did smoke, how
many pks daily? _______
Date: ______________
Drug Use:
□ No Drug Use
□ Quit Drug Use (When?) Date: _______________
Drug Used? _________
□ Intermittent Use
(Social 1x 1-3 months)
□ Intermittent Use
(Social 1x 1-3 months)
□ Occasional Use
(2-3 x monthly )
□ Occasional Use
(2-3 x monthly )
□ Daily Use
(1-2 x Daily )
□ Daily Use
(1-2 x Daily )
□ Smoke (Non-Tobacco)
How often exposed?
□ Smoke (2nd Hand)
How often exposed?
□ Chemicals (________)
How often exposed?
Drug Used? _________
Environmental Exposure:
□ Pets / Animals
How often exposed?
Name:__________________
Daily:
___________
Weekly: ___________
Monthly: ___________
Date of Visit: __________________
Daily:
___________
Weekly: ___________
Monthly: ___________
Daily:
___________
Weekly: ___________
Monthly: ___________
Daily:
___________
Weekly: ___________
Monthly: ___________
Travel History:
Have you traveled outside of the US recently? Where and When?
Country / Date:
/
Country / Date:
/
Country / Date:
/
Country / Date:
/
Medication History:
List only medications currently being taken; include over the counter drugs and vitamins/supplements.
Name:
Dose: (2 x daily, etc)
Name:
Dose: (2 x daily, etc)
Past Surgical:
Name of Procedure:
Date Performed:
Where/Who performed by:
Diagnostic Studies:
Have you had any test(s) (x-rays, CT scan, MRI, etc) performed in preparation for your visit today?
**Female patients: When was your last Mammogram? Date:______________________
Name of Procedure/Lab:
Date Performed:
Where/Who performed by:
Name:__________________
Date of Visit: __________________
Comments:
Is there any Medical History or Comments related to your condition(s) that you would like to note?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Review of Symptoms:
Are you experiencing or recently experienced any of the following:
General:
□ Appetite Loss
□ Fatigue
□ Fever
□ Night Sweats
□ Obesity
□ Weight Gain
□ Weight Loss
□ Unable to Sleep Lying Flat
□
Respiratory:
□ Bloody Sputum
□ Cough
□ Difficulty Breathing
□ Difficulty Breathing Exertion
□ Sputum Production
□ Wheezing
□ Waking with Shortness of
Skin:
□ Bruising
□ Itching
□ Nail Color Changes
□ Rash
□
□
□
□
□
Breast:
□ Breast Mass
□
□
□
□
□
□
HENT:
□ Headache
□ Nasal Congestion
□ Seasonal Allergies
□ Sleep Apnea
□ Snoring
□ Hoarseness
□
□
□
Cardiovascular:
□ Chest Pain
□ Edema
□ Palpitations
□ Swelling in Extremities
□
□
□
Neck:
□ Neck Mass
□ Swollen Glands
□
□
□
□
□
□
□
Gastrointestinal:
□ Diarrhea
□ Difficulty Swallowing
□ Heartburn
□ Nausea
□ Vomiting
□
□
Neurological
□ Decreased Memory
□ Seizures
□ Stroke
□ Weakness
□
□
□
□
□
□
□
Psychiatric
□ Anxiety
□ Change in Sleep Pattern
□ Depression
□ Early Awakening
□ Easily Irritated
□ Hypersomnia
□ Impaired Cognitive Function
□ Inability to Concentrate
□ Insomnia
□ Panic Attacks
□ Trouble Falling Asleep
Endocrine
□ Libido Changes
□ Thyroid Problems
□
□
Hematology
□ Blood Clots
□ Enlarged Lymph Nodes
□
□
□
□
Breath or Wheezing
Musculoskeletal
□ Join Pain
□ Muscle Pain
□ Muscular Weakness
□
□
□
□
□
□
□
□