Chart # _____
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520 North Elam Ave-Greensboro, NC 27403
Pulmonary Consultation Form
Name _______________________________________ DOB: ______________ Age: ________ Date: _________
Consult Requested by Dr. ____________________________________________ Self-Referred: Yes / No
HISTORY OF PRESENT ILLNESS:
What is the reason you are here? ____________________ When diagnosed? __________
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What is the main symptom/problem bothering you? _________ _
___ How Long? __ __ __
When does it occur? _____________________ What makes it better? _____
___________
What makes it worse? ____________
________________
Have you seen a Pulmonologist before?
Yes / No
If Yes, List name: _______
_______
CHECK TESTS YOU HAVE HAD FOR YOUR PROBLEM(S) AND APPROXIMATE DATES
 Labs _____________
_ ____
 Xrays___________
______
 Pulmonary Function Test ________ _____
Past Medical History
CHECK CURRENT OR PAST PROBLEMS
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High Blood Pressure
Heart Attack
Angina
Heart Failure
Heart Rhythm Problems
Asthma
Emphysema
Diabetes
High Cholesterol
Stroke
Blood Clots
Cancer
Allergy or Sinus Trouble
Chronic Headaches
HIV
Kidney Disease/Failure
Sleep Apnea
Disorder of the Nervous System
List all other Problems/ Surgeries
_________________________________
CHECK PRIOR SURGERIES/APPROXIMATE
DATE
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Splenectomy _____ ___________
Gallbladder__________ _______
Lung Surgery ______ __________
Neck/Back Surgery ____________
Colon Surgery _________ ______
Sinus Surgery _________ _______
Heart Valve ____________ _____
Heart Bypass__________ _______
Angioplasty/ Stent _____ _______
Hysterectomy _______ ________
Tubal Ligation _______ ________
Breast __________ ___________
Appendix ___________ ________
Organ Transplant ________ _____
HAVE YOU EVER BEEN EXPOSED TO:
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Tuberculosis
MEDICATION ALLERGIES/REACTION :____________________________
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Latex Allergy? Yes / No
IV Contrast or Iodine Allergy? Yes / No
Aspirin Intolerant? Yes / No
Have you ever taken Prednisone? Yes / No
If yes, when was your last dose? _______________
SOCIAL HISTORY:
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PLEASE CIRCLE:
I smoke How much? ___________ _ (ppd)
I quit smoking When? _____________
I use smokeless Tobacco
I drink Alcohol How much? ________
I Quit Drinking What? __________ __
I use drugs What type? ___________
I quit using drugs When? ________ __
At risk for HIV
I am: Single
Married
Divorced
Separated
Widowed
Children: Yes / No
FILL IN:
I live with: ___________________
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My occupation Is: ________________
___________
Any recent travel (last 3 months)___________________ __
FAMILY HISTORY:
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Emphysema _____________
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Allergies _______________ __
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Asthma ____________
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Heart Disease __________
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Clotting Disorders ______
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Rheumatism _____
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Cancer _____________
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CHECK PROBLEMS YOU ARE HAVING OR HAVE HAD RECENTLY
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Shortness of Breath With Activity
Shortness of Breath at Rest
Productive Cough
Non-Productive Cough
Coughing up Blood
Chest Pain
Irregular Heartbeats
Acid Heartburn
Indigestion
Loss of Appetite
Weight Change
Abdominal Pain
Difficulty Swallowing
Sore Throat
 Tooth/Dental Problems
 Headaches
 Nasal Congestion/Difficulty Breathing
Through Nose
 Sneezing
 Itching
 Ear Ache
 Anxiety
 Depression
 Hand/Feet Swelling
 Joint Stiffness or Pain
 Rash
 Change in Color of Mucus