PULMONARY HEALTH QUESTIONNAIRE

PULMONARY HEALTH QUESTIONNAIRE
Patient Name

First Name Middle Name Last Name
Date

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Reason for Visit
Past History
Have you ever had

Asthma Emphysema Bleeding Problems Stroke Tuberculosis Pneumonia Kidney Problems Ulcers Seizures Diabetes Liver Problems Arthritis Heart Attack High Blood Pressure Heart Problems Blood Clots Cancer Thyroid Problems
Have you ever had Surgery?

Yes No
Type of surgery
Date

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Type of surgery
Date

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Type of surgery
Date

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Type of surgery
Date

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Social History
Do you use tobacco?

Yes No
What Type?

Cigarettes Chew Pipe Cigars
#/Day
How many years
When did you quit?

Month Day Year Date Picker Icon
Do you drink alcoholic beverages?

Yes No
How many per week?
Have you ever used marijuana or any other illicit drug?

Yes No
Do you tolerate physical exercise well?

Yes No
Have you traveled/lived abroad?

Yes No
Do you have trouble sleeping?

Yes No
Do you have pets?

Yes No
What kind of pets?
List of Medications & Dosage
Allergies
Are you allergic to any medications?

Yes No
Which medications?
Other allergies
Family History

	Age (if living)	Age at Death	State of Health/Cause of Death
Mother
Father
Brother/Sister
Brother/Sister
Brother/Sister
Children
Children
Spouse/Partner

Review of Systems – Please check all that apply
General

Weight changes Sleeping Problems Loud Snoring Fevers/Chills/Sweats
Skin

Skin Rash Itching New Skin Marks/Spots
Head/Eyes/ Ears/Nose/Throat

Visual Problems/Changes Itching Eyes/Nose Nose Bleeds Drainage from Nose Sinus Infections Hoarseness Sore Throats Headaches
Respiratory

Coughing Wheezing Shortness of Breath Bronchitis Frequent Colds Coughing Up Blood
Cardiovascular

Chest Pain Heart Attack Heart Murmur Palpitations Irregular Heart Beat Short of Breath w/ Walking Dizziness Swelling of Feet/Ankles
Gastrointestinal

Nausea/Vomiting Vomiting Blood Difficulty Swallowing Heartburn/Indigestion Abdominal Pain Constipation Diarrhea Bloody/Black Stools
Genitourinary

Pain with Urination Frequent Urination Blood in Urine Kidney Stones
Musculoskeletal

Joint Pain/Swelling Back Pain Muscle Pains/Aches
Neurological

Numbness Tingling Weakness/Paralysis Tremors Seizures
Psychological

Depression Anxiety/Panic Attacks
Other Medical Problems Not Listed
Patient Signature: ____________________________________________ Date: ________________
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