PULMONARY AND SLEEP PHYSICIANS OF HOUSTON, P.A.
501 ORCHARD, SUITE 200. WEBSTER, TX. 77598 TEL.: 281-557-8555 FAX: 281-554-3657
Niranjan Iyer, M.D.
Alfred Maksoud, M.D.
F. Adam Kawley
S. Hyder Jaffery, M.D.
Patient Intake Questionnaire
NAME ___________________________________________________ AGE ________
DATE ______________
Referring Physician ___________________________________________ Office # (______) ________________
PAST ILLNESSES: (Check all that apply)
 Abnormal heart beat  Angina/Chest pain
 Asthma
 Allergies/Hay Fever
 Arthritis
 Blood Clots
 Blood Problem
 Chronic Sinus Problems
 Chronic obstructive pulmonary
disease/ Emphysema
 Cancer (site ____________________)
Previous treatment:
 Surgery
 Radiation
SOCIAL HISTORY:
Tobacco:
 Never Smoked
 Active Smoker
 Ex-Smoker
Quit______Years Ago
Years Smoked_______
Packs per Day Smoked______
Recreational Drug Use?
Yes
No
Alcoholic Beverages:
 Never
 Less than 1 per week
 1-5 per week  Other_____________
Major Hobbies:
_______________________________________
 Chemotherapy
 Diabetes
 Eye problems
 Heartburn/GERD
 Heart Attack
 Hiatal Hernia
 High Blood Pressure
 Heart Failure
 Liver Problem
 Kidney Problem
 Pulmonary Fibrosis
 Pneumonia
 Skin Problems
 Sarcoidosis
 Stroke
 Stomach Ulcer
 Tuberculosis
 Thyroid Problems
 Weight Loss Medication use
 Fracture ( site_______________)
______________________________________
Foreign travel in last year__________________
Have you had any serious illness? Yes No
Have you ever been hospitalized or under
medical care for very long? Yes
No
If Yes, for what reason?
______________________________________
US travel in last year _____________________
Do you have any pets?
Yes
No
Type________________ How Many________
OCCUPATIONAL HISTORY:
Employment:
 Full time
 Part Time  Retired
List major jobs you held throughout your life:
_______________________________________
______________________________________
_______________________________________
OPERATIONS: (Check all that apply)
 Appendectomy
 Gallbladder
 Heart Bypass Surgery  Heart Valve Surgery
 Hysterectomy
 Joint Replacement
 Lung Surgery
 Vascular Surgery
 Mastectomy
 Inguinal Hernia Repair
 Other
_______________________________________
_______________________________________
_______________________________________
_______________________________________
Have you ever worked with asbestos? Yes No
Exposed to fumes, Dust or Solvents? Yes No
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NAME: _______________________________
Patient Intake Questionnaire
How much time have you lost from work because
of breathing problems during the past…?
Six Months_______
One Year_______
Five Years________
SLEEP HISTORY:
Do you sleep all night?
Do you snore?
Do you have a bed partner?
Have you been told that you stop
breathing while asleep?
Do you wake up tired after sleeping?
Do you fall asleep easily watching TV?
Do you fall asleep at work?
Yes/No
Yes/No
Yes/No
Have you fallen asleep at the wheel?
Do you have nightmares?
Do you feel confused upon awakening
Do you grind your teeth at night?
Do you kick/ twitch your legs at night?
Do you feel paralyzed upon falling
asleep or upon awakening?
Are you a student?
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
FAMILY HISTORY:
Family
Member
Age
Health
Age at Death
(If Deceased)
Major Health Problems
Father
Mother
Brother/Sister
Have either parent, brother, sister, or grandparent ever had? (Check all that apply)
 Stroke
 Heart Trouble
 Diabetes
 Asthma
 COPD/Emphysema
 High Blood Pressure
 Cancer
 Sarcoidosis
 Pulmonary Fibrosis
MOST RECENT VACCINATIONS:
Flu Vaccine ____________ (Date)
Pneumonia _____________ (Date)
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 Bleeding Tendency
 Tuberculosis
NAME: _______________________________
Patient Intake Questionnaire
LIST CURRENT MEDICATIONS (Including Herbs and over the counter medications/ supplements)
Medications
Dose
How Often
**If list is longer than boxes provided, continue list on back of this form**
Do you use mineral oil, mineral oil nasal drops, or petroleum products?
Yes
No
PLEASE LIST ANY MEDICINE/FOOD/ENVIRONMENTAL ALLERGIES:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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NAME: _______________________________
Patient Intake Questionnaire
CHECK ALL THAT APPLY
SYSTEMIC/CONSTITUTIONAL:
 Fevers
 Chills (bed shaking)
 Night Sweats
 Weakness
 Recent weight change
 Loss_______Lbs.  Gain_______Lbs.
Energy Level
 Excellent
 Good
 Fair
 Poor
HEART:
 Chest Pain, Pressure or Tightness
 Shortness of breath lying down
 Shortness of breath that awakes you from
sleep
 Palpitations
 Difficulty walking more than 2 blocks
 Swelling of feet or ankles
 Heart murmur
HEENT:
 Blurry Vision
 Wear Glasses
 Dry Eyes
 Runny Nose
 Sinus Congestion  Chronic Sinus Problems
 Post Nasal Drip
 Allergy Symptoms
 Hoarseness
NEURO-PSYCHIATRIC:
 Trouble Hearing
 Fainting Spells
 Convulsions or Seizures
 Headaches
 Change in mood
 Paralysis
 Coordination Problems
 Depression
 Anxiety
NECK:
 Stiffness
GASTROINTESTINAL:
 Pain with swallowing
 Difficulty swallowing
 Does food get stuck in your throat?
 Change in appetite
 Hepatitis
 Jaundice
 Blood in stool
 Change in bowel habits
 Frequent Diarrhea
 Constipation
 Heartburn or Indigestion
 Pain in abdomen
 Swelling or Masses
URINARY:
 Loss of urine
 Difficulty Urinating
 Pain Urinating  Blood in Urine
 Kidney Trouble
LUNGS:
 Asthma or Wheezing
 Cough
 Coughing blood
 Difficulty Breathing
 Pain with deep breathing  Pleurisy
 Sarcoidosis
 Shortness of breath at rest
 Shortness of breath with activity
How much activity? ____________________
 Shortness of breath climbing more than 1 flight of
stairs
 Other Lung Problems
Define your lung problems _______________
HORMONAL:
 Excessive Thirst
 Excessive Urination
 Diabetes
 Thyroid Problems
 Heat or Cold intolerance
MUSCLES AND BONES:
 Arthritis Symptoms
 Joint Pain or Swelling
 Weakness of muscles
 Difficulty walking
_______________________________________
_______________________________________
SKIN:
 Skin Disease
 Jaundice
 New Rash
 Eczema
LYMPH GLANDS/BLOOD:
 Enlarged Glands  Easy Bruising
 Easy Bleeding
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