premierlungandsleep.com - New Patient Intake Questions.

New Patient Intake Pulmonary
1. What is your main breathing complaint?
2. How long has this been a problem?
3. Were there any events (travel, hospitalization, illness/infection, etc.) associated with onset?
4. Have you had any treatment for this complaint already? Over the counter medications?
5. Have you been on any antibiotics in the last 3 months?
6. Have you had any oral Steroids in the last 3 months (medrol, prednisone, dexamethasone)?
7. Have you ever been told you have Chronic obstructive pulmonary disease (COPD)? If yes need to fill out CAT and MMRC questionnaire.
COPD Assessment Test (CAT)
Patients rate symptoms on a scale of 0–5, where 0 = no symptoms / not affected and 5 = worst symptoms / severely affected.
The total score is the sum of 8 questions (0–40).

Questions:
1. How often do you cough?

0

1

2

3

4

5

0 is Never , 5 is All the time
2. How much phlegm (mucus) do you have in your chest?

0

1

2

3

4

5

0 is No phlegm, 5 is full of phlegm
3. How tight does your chest feel?

0

1

2

3

4

5

0 is No tightness, 5 is Very tight
4. How breathless do you get when walking up a hill or stairs?

0

1

2

3

4

5

0 is Not breathless, 5 is Very breathless
5. How limited are you doing activities at home?

0

1

2

3

4

5

0 is Not limited, 5 is Very limited
6. How confident are you leaving your home despite your lung condition?

0

1

2

3

4

5

0 is Confident, 5 is Not confident
7. How well do you sleep?

0

1

2

3

4

5

0 is Sleep soundly, 5 is Don’t sleep soundly
8. How much energy do you have?

0

1

2

3

4

5

0 is Lots of energy, 5 is No energy at all
MRC Dyspnea Scale
Patients are asked to choose one statement (Grade 0–4) that best describes their level of breathlessness:

Grade 0: I only get breathless with strenuous exercise.Grade 1: I get short of breath when hurrying on level ground or walking up a slight hill.Grade 2: On level ground, I walk slower than people of the same age because of breathlessness, or I have to stop for breath when walking at my own pace.Grade 3: I stop for breath after walking about 100 yards (or after a few minutes) on level ground.Grade 4: I am too breathless to leave the house, or I get breathless when dressing or undressing.
8. Have you ever been told you have asthma?
9. Have you ever been treated with any respiratory inhalers (albuterol, trelegy, breo, symbicort)?

YesNo
If so, which one and how long did you try the inhaler?
10. Have you ever had a blood clot in your legs or lungs?

YesNo
If so, when/where and what treatment?
11. Are you on any anticoagulants or blood thinners?
Ex: Eliquis, Xarelto, coumadin(warfarin), Aspirin, Plavix, brilinta
12. Do you use Bipap/CPAP?
13. Do you have allergies?

YesNo
If so, what type

SeasonalFoodEnvironmental (pollen, trees, grass etc)?
What season
Type
14. Have you had any lung surgeries? Any Lung biopsies? Any other Lung procedures?
15. When was the last time you were hospitalized? And for what reason?
16. Did you have your influenza vaccination, Approx date received
17. Did you have your pneumonia vaccination, approx date recieved
Should be Empty:

New Patient Intake Pulmonary

COPD Assessment Test (CAT)

MRC Dyspnea Scale