bhsleepcenter.com - PULMONARY MEDICINE

Patient Medical History Questionnaire
Please complete this brief questionnaire before your visit. Your answers will help us understand your concerns and make the most of your time with Dr. Ansari. Please discuss any additional concerns during your appointment.
1. Patient information
Full name:
Date of birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary care physician:
What is the main reason for your visit?

Other
When did your symptoms begin?
2. Current Symptoms
Please check all that apply.
Do your symptoms interfere with walking, exercise, work, or daily activities?
Have your symptoms recently worsened?
Additional details:
3. Medical History
Have you ever been diagnosed with any of the following?

Other
4. Smoking and Exposure History
Smoking history
If applicable, number of packs per day:
Years smoked:
Date quit (if applicable):

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other smoking or inhalation history:
Occupational or environmental exposures (dust, chemicals, mold, asbestos, etc.)
If yes, please describe the exposures:
5. Medications and Allergies
Please list your current inhalers, respiratory medications, oxygen use, and other important medications.
Medication allergies and reactions:
If yes, please list medication allergies and reactions:
Home oxygen use
If yes, oxygen flow rate:
6. Prior Testing and Treatment
Have you had any of the following?
Approximate dates or locations, if known:
7. Your Priorities
What is the most important question or concern you would like to address during your visit?
Should be Empty:

Patient Medical History Questionnaire

1. Patient information

2. Current Symptoms

3. Medical History

4. Smoking and Exposure History

5. Medications and Allergies

6. Prior Testing and Treatment

7. Your Priorities