Limestone Pulmonary and Sleep Associates P.C.
101 Fitness way, Suite 2500, Athens, AL-35611
Ph: 256-262-6720 Fax: 256-206-8100
Name: ____________________________________________________ DOB: ______________ DOS: _______________
Reason for Visit: ____________________________________________________________________________________
Chief complaint that brings you to our office today: ________________________________________________________
Please check any of the following symptoms you have:
 Chest Pains
 Cough
 Coughing up Blood
 Difficulty with sleep
 Daytime Sleepiness (Excessively tired)
 Frequent awakenings while sleeping
 Leg Swelling
 Shortness of Breath
 Sinus Problems
 Snoring
 Sputum or Mucous Quantity
 Wheezing
 Others _________________
_________________________
How long have you had these symptoms? _______________________________________ days/weeks/months/years
How severe are your symptoms?
 Mild  Moderate  Severe
Do you consider your symptoms to be
 Stable  Getting Worse  Improving
When are the symptoms worse?  Throughout the day  at night
 in the morning
Please check any of the following that makes it harder for you to breathe:
 Cold Weather
 Cold or Flu
 Sinus Infections
 Smoke
 Stressful Events
 Warm Weather
 Other: ______________________________________________________________________
What improves your symptoms?
 Inhalers
 Humidifiers
 Avoiding Allergens
 Others: ________________________
Please check any of the following associated symptoms:
 Weight Loss
 Weight Gain
 Anxiety
 Acid Reflux
 Other: _____________________________________________________________________________
Current Medications (Include all Prescriptions, Supplements, Over the Counter and Herbal Medications)
Name
Dosage
Frequency
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Limestone Pulmonary and Sleep Associates P.C.
Allergies/Intolerances
Do you have allergies / intolerances to Medication or other substance
 No  Yes
If yes, please list the medication and the reaction
Medication
Reaction
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2
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Past and Current Medical History:
 Allergies
 Bipolar Disorder
 GERD/reflux
 Obesity
 Arthritis
 COPD
 Heart Disease
 Sinus problems
 Asthma
 Depression
 High Blood Pressure
 Stroke
 Atrial fibrillation
 Diabetes
 High Cholesterol
 Sleep Apnea
 Anxiety Disorder
 Emphysema
 Lung Cancer
 Thyroid problems
 Others (please list) ________________________________________________________________________________
______________________________________________________________________________________________
Did you have any surgeries in the past:  No  Yes if yes please list below
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Father
Mother
Others (Please specify)
____________________
Family History (Please check all applicable)
Medical Problems
 COPD
 Asthma
 Cancer
 High Blood Pressure
 Sleep Apnea
 Heart Disease  Diabetes
 Others __________________________________________________________________
 COPD
 Asthma
 Cancer
 High Blood Pressure
 Sleep Apnea
 Heart Disease  Diabetes
 Others __________________________________________________________________
 COPD
 Asthma
 Cancer
 High Blood Pressure
 Sleep Apnea
 Heart Disease  Diabetes
 Others __________________________________________________________________
Social History:
What is your marital status?
 Single  Married  Divorced  Widowed  Other
Did you ever smoke ?  Yes  No
Quit?  Yes  No If quit, please indicate when: _____________________________________________________
 Cigarettes: # __________ pack(s) per day for ______________ years
 Cigars: # __________ cigar(s) per day for ______________ years
 Chewing Tobacco: for ______________ years
Do you drink alcohol?  No  Yes – how often do you drink? ___________________________________________
Do you use any of the following:
 Marijuana  Heroine  Cocaine  Other: ____________________________
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Limestone Pulmonary and Sleep Associates P.C
Do you currently work?  Yes  No
Please list your current and past jobs: ___________________________________________________________________
__________________________________________________________________________________________________
Have you ever been exposed to any Toxic Environmental or Occupational Inhalants?  Yes  No
If yes, please describe in detail: ________________________________________________________________________
__________________________________________________________________________________________________
Immunization History:
Have you ever had a pneumonia shot (Pneumovax)?  Yes  No
Do you get a yearly influenza shot (flu shot)?  Yes  No
Review of Systems:
Please check any other symptoms you currently have:
 Weight Gain  Weight Loss  Fever  Chills  Feeling Tired/Fatigue  Other: ________________
General:
Head:
 Headache  Sinus  Other: _______________________________________________________________
Eyes:
 Itchy Eyes  Watery Eyes  Other: _________________________________________________________
ENT:
 Itchy Throat  Sore Throat  Nasal Congestion  Runny Nose  Post Nasal Drip  Hoarseness
 Other: ___________________________________________________________________________________
Cardiovascular:
 Wheezing  Shortness of breath  Cough  Sputum  Other: ____________________________
Respiratory:
Gastrointestinal:
Endocrine:
 Chest Pain  Chest Tightness  Palpitations  Leg Swelling  Other: ___________________
 Heartburn  Diarrhea  Constipation  Other: ______________________________________
 Excessive Thirst  Excessive Urination  Other: __________________________________________
Heme/Lymph:
 Easy Bruising  Easy Bleeding  Other: ______________________________________________
Musculoskeletol:  Joint Pains  Joint Swelling  Other: ________________________________________________
Skin:  Rash  Itching  Other: ____________________________________________________________________
Neurologic:  Sleep Disturbance  Dizziness  Poor Concentration  Excessive daytime sleepiness
 Other: ___________________________________________________________________________________
Psychiatric:
 Depression  Anxiety  Insomnia  Other: _____________________________________________
Allergy/Immunologic:  Pollen  Grass  Mold  Dust Mites  Cats  Dogs  Other _______________________
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