premierlungandsleep.com - New Patient Intake

New Patient Intake Pulmonary
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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:
8. Have you ever been told you have asthma?
9. Have you ever been treated with any respiratory inhalers (albuterol, trelegy, breo, symbicort)?
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?
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?
If so, what type
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