Omar Tirmizi, MD
West LA Pulmonary Medical Group
Patient Name: ______________________________________________________________ Date: ___________________________
(Last)
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The following are questions which will help me decide which problems if any we need to discuss further.
If you do not understand a question do not answer it.
Please circle your answer.
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Overall, was your childhood a healthy one? ……………………………………………………………….. yes
Have you ever had rheumatic fever (growing pains, St Vitus dance or heart murmur)?................. yes
Have you ever had pneumonia or pleurisy?.......................................................................................... yes
Have you ever had any contact with anyone with tuberculosis?...................................................... yes
Have you ever had any allergies such as asthma or hay fever?(wheezing spells)…………………… yes
Have you ever had any serious injuries? ……………………………………………………………………….. yes
Have you ever had any operations? …………………………………………………………………………. yes
Are you subject to headache? ………………………………………………………………………………… yes
Do you have any trouble with your eyes (dryness, scratchiness, or double vision)?......................... yes
Do you have any hearing trouble or ringing in your ears? ………………………………………………... yes
Do you have any sinus trouble? ………………………………………………………………………………… yes
Do you bleed from your nose or gums? ………………………………………………………………………. yes
Do you have any trouble with your teeth or tongue (soreness) ………………………………………….. yes
Do you have frequent sore throats or hoarseness? ………………………………………………………… yes
Do you have trouble swallowing? ……………………………………………………………………………... yes
Does food stick on the way down? ……………………………………………………………………………. yes
Have you ever had goiter (enlarged thyroid) or thyroid trouble? ………………………………………. yes
Is your skin or hair dry? …………………………………………………………………………………………….. yes
Is your hair falling out too much? ……………………………………………………………………………….. yes
Do you feel colder or warmer than other people? …………………………………………………………. yes
Do you sweat at night to the point of having to change your bed clothes? ……………………….... yes
Have you ever had high/ low blood pressure? ……………………………………………………………... yes
Have you ever been told you have a murmur in your heart? ……………………………………………. yes
Do you get short of breath when you walk or climb stairs? ………………………………………………. yes
Do you awaken at night short of breath? ……………………………………………………………………. yes
Do you have any ankle swelling? ……………………………………………………………………………… yes
Have you had any pain or discomfort in your chest? ……………………………………………………… yes
Have you had palpitations of the heart? …………………………………………………………………….. yes
When you walk do you get pains in the calves of your legs? ……………………………………………. yes
Do you cough daily? yes no…………. do you bring up sputum? ………………………………..
yes
Have you had any heartburn, excessive gas or pain in your stomach? ………………………………. yes
Do you wheeze or develop chest tightness? ………………………………………………………………… yes
Do you throw-up or feel like throwing up? …………………………………………………………………… yes
Have you ever had a stomach or duodenal ulcer? ……………………………………………………….. yes
Have you thrown up blood? ……………………………………………………………………………………. yes
Have you had any blood in your bowel movements? ……………………………………………………. yes
Have you ever had any black or tarry looking bowel movements? …………………………………… yes
Have you ever had any excessive mucus in your bowel movements? ……………………………….. yes
Have you ever had jaundice (yellowness of the eyes, skin or dark urine or hepatitis)? ……………. yes
Are you constipated? …………………………………………………………………………………………….. yes
Any changes in your bowel habits recently such as pencil-sized bowels movements?.................... yes
Are you troubled by diarrhea? ………………………………………………………………………………….. yes
During the day time do you urinate more often than usual?............................................................... yes
Do you get up at night to urinate? If so how often________? ……………………………………………. yes
Are you drinking more water than you used to? (more than 10 glasses of all kinds of fluids)………. yes
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Do you have pain or burning when you urinate? …………………………………………………………… yes no
Have you ever had a bladder or kidney infection? ………………………………………………………… yes no
Have you ever had a kidney stone? …………………………………………………………………………… yes no
Do you wet your pants when you cough or sneeze? ……………………………………………………… yes no
Have you had any blood when you urinate? ……………………………………………………………….. yes no
Have you ever had syphilis or gonorrhea? ……………………………………………………………………. yes no
Do you get dizzy spells? …………………………………………………………………………………………… yes no
Do you faint? ……………………………………………………………………………………………………….. yes no
Have you ever had any fits or convulsions? ………………………………………………………………….. yes no
Have you ever had paralysis of any part of the body? ……………………………………………………. yes no
Have you ever any numbness of any part of the body? …………………………………………………… yes no
Do you get shaking spells? ……………………………………………………………………………………….. yes no
Do you get backaches? ………………………………………………………………………………………….. yes no
Do your fingers turns white, blue, red or become painful in the cold? …………………………………. yes no
Do you have pain in your muscles? …………………………………………………………………………….. yes no
Do you have pain or swelling in your joints?........................................................................................... yes no
Have you ever had a rash from being in the sun?.................................................................................. yes no
Have you ever had psoriasis or any other rashes? ………………………………………………………… yes no
What’s your usual weight (approximately)? ………………………………………………………………… _________
What is the most you’ve ever weighed (approximately)………………………………………………… _________
In the last 3 months, has your weight changed more than 5 pounds? ………………………………… yes no
Have you ever been anemic? ………………………………………………………………………………….. yes no
Have you ever had any persistent fever or chills…………………………………………………………….. yes no
Do you take any meds such as aspirin, drugs or vitamins? ………………………………………………. yes no
Have you ever had a reaction to medicine (such as penicillin or sulfa)? ……………………………... yes no
Have you been a smoker? ………………………………………….………………………………………….. yes no
Do you drink alcohol at all? (including beer or wine) ………………………………………………………. yes no
Do you have trouble falling asleep? …………………………………………………………………………… yes no
Do you wake up during the night without apparent reason? ……………………………………………. yes no
Do you feel light headed or faint? ……………………………………………………………………………… yes no
Are you or have you been a nervous person? ………………………………………………………………. yes no
Do you snore? ………………………………………………………………………………………………………. yes no
FOR MEN ONLY
78. Do you dribble when you have finished urinating? ………………………………………………………… yes
79. Does your stream come out with less force than before? ………………………………………………… yes
80. Have you had any discharge from your penis? …………………………………………………………….. yes
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FOR WOMEN ONLY
82. How old were you when you started to menstruate? ……………………………………………………… ________
83. Overall, are or were your on regular cycles?........................................................................................... yes no
84. When was your last menstruation period? ………………………………………………………………_______________
85. Do you or did you have pain with your menstrual period?................................................................... yes no
86. Are you pregnant? ……………………………………………….……………………………………………….. yes no
87. Did you have any complications with your pregnancy? ………………………………………………….. yes no
88. Do you have any vaginal discharge? …………………………………………………………………………. yes no
89. Are you getting hot flashes or going through menopause? ……………………………………………… yes no
90. Are you taking contraceptive or estrogen pill? ……………………………………………………………… yes no
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