NEW PATIENT PAPERWORK

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Filling Out This Form (if not the Patient)

First NameLast Name
Date of Birth*

MonthDayYear
Cell Phone*
Phone
Home Phone
Phone
SSN*
Email Address*
example@example.com
Employer
Occupation
Primary Language*
Race
Marital Status
Gender at birth
Emergency Contact*
Relationship to Patient*
Phone for Emergency Contact*
Phone
Primary Doctor
Referring Doctor
Pharmacy
Other Doctors Treating You Cardiologist Rheumatology ENT Oncologist
Tell us what brings you in today?

	Likelihood of falling asleep
Sitting and Reading
Watching TV
Sitting, inactive in a public place (theater, meeting, etc)
As a passenger in a car for an hour without break
Lying down to rest in afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic

Medications/ Allergies
Do you have any environmental or drug allergies?*

YesNo
If yes, please list along with reaction.
Please List all Prescribed and over the counter medications

Assignment of Benefits

I understand that I am financially responsible for all charges whether or not covered by insurance. I authorize the release of any medical or other information necessary to process any claim for medical care. I hereby authorize the Practice to bill my insurance company and/or Medicare for services provided to me and request that payments for such services to made to the Practice on my behalf.
Signature of Patient or Legal Guardian*

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Printed Name*
Relationship if not patient*
Date*

MonthDayYear
Date
Patient Agreement Regarding Social Media and Online Posts

To ensure a respectful, professional, and safe environment for both patients and staff, Independent Lung Associates kindly requests adherence to the following policy: Online Posting & Social Media Policy By signing below, I acknowledge and agree to the following: 1. Confidentiality and Respect: I will not post any comments, reviews, photos, or other content on the internet or social media platforms that include the names, images, or identifiable information of Independent Lung Associates staff or providers without their express written consent. 2. Business Representation: I understand that I may not publicly share or publish information (written, video, audio, or photographic) about my experience at Independent Lung Associates in a way that misrepresents, harms, or defames the practice or any of its team members. 3. Consent Required: Any content referring to Independent Lung Associates, its name, logo, employees, or medical services must not be posted online or distributed publicly without prior written consent from an authorized representative of the practice. 4. Acknowledgment: I understand that violation of this agreement may result in termination of care, and in certain cases, legal action as appropriate.

This policy is not intended to limit any rights under applicable federal or state laws but rather to protect the privacy and professionalism of all individuals involved.
Signature of Patient or Legal Guardian*

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Printed Name*
Relationship if not patient
Date*

MonthDayYear
Date

Should be Empty:

	Parent	Grandparent	Sibling	Children	Comments
Stroke
Copd
Sleep Apnea
Asthma
Narcolepsy
Heart Attach
Alpha one deficieny

	Yes	No	Sometimes	Comments
Fever
Fatigue
Night Sweats
Excessive weight gain
Excessive weight loss

	Yes	No	Sometimes	Comments
Productive cough
Cough with blood
Difficultly breathing at rest
Difficulty breathing with activity only
Wheezing
Dry Cough
Chest tightness

	Yes	No	Sometimes	Comments
Chest Pain
Leg swelling or fluid retention
Palpitations
Shortness of breath
Waking at night with chest pain
Waking at night with shortness of breath
Chest tightness

	Yes	No	Sometimes	Comments
Glaucoma
Nasal Congestion
Post Nasal Drip
Hoarseness
Seasonal allergies
Headaches
Sinus pain

Social HIstory

Family History

Medical History

Medications/ Allergies

	Yes	No	Sometimes	Comments
Depression
Problems concentrating
Double vision
Weakness
Memory issues
Speech issues

	Yes	No
Hallucinations upon falling asleep or upon waking
Crawling and or aching sensations in your legs
Do you do shift work or work varied hours?
Do you usually drink caffeine within 2 hours of bedtime?
Awaken from sleep gasping for air or short of breath
Have you been told that you snore?
Do you sweat excessively at night?
Does your heart pound or beat irregularly when asleep?
Do you feel sleepy during the day?
Do you fall asleep involuntarily and or while driving?
Do you feel weak or lightheaded with laughing or crying?
Feel paralyzed when waking or falling asleep?
Experience vivid dreamlike scenes when waking up or falling asleep?
Family history of sleep apnea?

	Yes	No	Past	Comments
Asthma
Chronic sinusitis
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Sleep Apnea
Chronic cough
Pulmonary Fibrosis
Pulmonary Hypertension
Narcolepsy
Autoimmune disorders
Pulmonary Embolism
Pleural Effusion
alpha 1 deficiency

	Yes	No	Past	Comments
Heart Attack
Other Heart disease
Stroke
Elevated cholesterol
Arrhythmia (irregular heart rate)
Hypertension (high blood pressure)
Rheumatic fever
Mitral valve prolapse
Congestive Heart Failure
Pacemaker
Defibrillator

	Yes	No	Sometimes	Comments
Easy bruising
Rashes