New Patient Intake forms

Comprehensive Pulmonary Test

Medical Intake
This form will serve as a medical intake, which will be recorded for quality assurance and training purposes. We will only use this information to only contact you about this test. Your information is secure and we do not share it.
Product

Comprehensive CARDIO testComprehensive PULMONARY test
Have you ever taken an at home-cheek swab for cardiac or pulmonary genetic testing before?

YESNO
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Medicare ID Number:*
Medicare Advantage/Supplement?

YESNO
GENDER:*

MALEFEMALE
Ethnicity:*
Body weight (lbs)
Height (Feet)*
Height (Inches)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Main Phone Number*
Format: (000) 000-0000.
Second Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
What time is best to reach you?*
Texting Consent (May we text reminders for your follow-up appointment?)

YESNO
Primary Care Provider (first and last name)*
City and State
Patient Personal History:
PERSONAL History notes:

Have YOU ever been diagnosed?

Rows	YES	NO	Age?
Lung Disease (Asthma)
COPD
Interstitial lung disease
Emphysema
Pulmonary Fibrosis
Ciliary Dyskinesia
Bronchiectasis
Cystic Fibrosis
Metabolism Dysfunction
Collapse of part or all of the lung (pneumothorax or atelectasis)
Lung cancer
Blocked lung artery (pulmonary embolus)

Have YOU ever had symptoms pertaining to lung issues?

Rows	YES	NO	Age?
cough
Dyspnea
Orthopnea
shortness of breath
Stridor
Wheezing
periodic breathing
hyperventilation
Tachypnea
Asphyxia
Pleurisy
Cyanosis
abnormal blood-gas level
abnormal results of pulmonary studies
Hypoxemia

Social History*

Rows	Yes	No	Comments
Tobacco Usage History
Alcohol Usage History
Recreational Drug Usage History

Activities of Daily Living that patient CAN NOT do themself)

Bath yourselfBrush your teethComb your hairDress yourselfCook for yourselfAble to walk independently

Personal Allergies:

Rows	On going	Past	Comments
Food allergies
Environmental allergies
Multiple chemical sensitivites
Latex allergy
Pet allergies
other

FAMILY HISTORY:

Has anyone in your family (parents, grandparents, children, uncle/aunts, niece/nephew, cousins) ever been diagnosed with ... ?
Family History notes:

Have anyone in your FAMILY ever been diagnosed?*

Rows	YES	NO	Relationship	Age?
Lung Disease (Asthma)
COPD
Interstitial lung disease
Emphysema
Pulmonary Fibrosis
Ciliary Dyskinesia
Bronchiectasis
Cystic Fibrosis
Metabolism Dysfunction
Collapse of part or all of the lung (pneumothorax or atelectasis)
Lung cancer
Blocked lung artery (pulmonary embolus)

Medications

Personal medications List
Current medications for pulmonary issues?*
Bronchodilators. Bronchodilators are medications that usually come in inhalers — they relax the muscles around your airways. ... Inhaled steroids. ... Combination inhalers. ... Oral steroids. ... Phosphodiesterase-4 inhibitors. ... Theophylline. ... Antibiotics.
Allergy Medications?*
OK Great. That's all we needed to gather from you for right now. We will turn your file in to our eligibility team to verify the information you provided to make sure this test will be covered by your insurance. If everything comes back good, they will give you a call.

Please feel free to give us a call for any questions:

(888) 505 - 3536
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Comprehensive Pulmonary Test