Health questionnaire Intake April 2025

Health Questionnaire + Registration Form

Part 1
WELCOME to the office of
Dr. Bruce Millman

If you have any questions, please call us at
1-248-965-4165
First name*
Last name*
Date of Birth *

MonthDayYear
Mobile Phone number (cell preferred)*
If do not have cell, then enter 111-111-1111
Home Phone number (if have one)
Email address*
example@example.com
Only used for office administrative, appt reminders, practice updates, your financial account update. We do not sell any patient information
Primary care physician , Nurse Practitioner (NP), Physician Assistant *
Enter First and Last name. "NONE" if you don't have one. Ask us for some names of ones if you need one!
Primary care physician (or Nurse practitioner, Physician assistant) phone number*
Primary care physician (or Nurse practitioner, Physician assistant) FAX number number--- we need this to send our reports to*
How did you hear about us?*
Ask our manager for details--if you refer a pleasant patient , we offer a superb $50 Amazon gift card to you.
Name of person who referred you to us?
Name of person who referred you to us?

Consent
Please review our office policy (including No show, cancellation policies and fees)

Office policy update Oct 1 2020 ---(Right click on this to open in a new window)
I have read the above office policy and also understand the fees apply to all patients (new, inpatient, followups). *

Clear

FAMILY Pulmonary history
Father have/had confirmed sleep apnea, asthma, COPD, sarcoidosis, blood clots, lung cancer, or lung disease *
If none, please enter NO
Mother have/had confirmed sleep apnea, asthma, COPD, sarcoidosis, blood clots, lung cancer, or lung disease? *
If none, please enter NO
Sibling have/had confirmed sleep apnea, asthma, COPD, sarcoidosis, blood clots, lung cancer, or lung disease ? *
If none, please enter NO

Medications + Allergies
Medication list*
Heading
Medication list upload (please make sure legible with doses)--PDF, JPG, JPEG, PNG only

Upload your medication list
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List all of your current medications (include all inhalers and/ or nebulizer medications) *
If you uploaded instead, type "uploaded"
List all ALLERGIES to MEDICATIONS , LATEX, IODINE DYE, TAPES, etc.*
If you don't have any, type "NKDA" (no known drug allergies)

Any other pertinent info that you want to upload?

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IMPORTANT: To help optimize your care quickly

At your first appointment, please bring---

1. CD-ROM for any Chest CT scans or chest X-rays from outside the Beaumont system. This way Dr. Millman can look at the images directly. This is the best way for the doctor to really understand your condition.

2. PAPER REPORTS of any ...
- Chest CT scans
- Chest x-rays
- ECHOcardiogram (from your cardiologist office)
- Sleep study reports from your current medical equipment company [call them to fax to our office directly]
3. A list of your inhalers or nebulizer treatment solutions
I will try to get records as above*

Yes, I am a stellar patient and will help out by calling my cpap equipment company or other medical team membersYes, I am a dedicated patient. I will call my doctor’s office and will have them fax records to Dr. Millman’s officeNo, I don’t want to take the time to do this, but understand that this will delay diagnosis and treatmentI don’t have any records that are pertinent to my medical care at all (recent non Beaumont records).
Any other comments or suggestions?

Click the below "REVIEW" button to review your answers so far. We suggest to print and bring to your appointment as well (in case there are any upload issues). After reviewing your answers, then you will be taken to our PART 2 sleep questionnaire to complete as well. Thank you!
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Health Questionnaire + Registration Form