New Patient Medical History Form

First Name

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Last Name

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Date of Birth:

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Date:

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Primary Care Provider:

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Why are you seeing a pulmonary (lung) provider?

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Have you recently been hospitalized?

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When?

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Where:

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Have you recently been in Urgent Care?

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When:

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Where:

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Have you recently had a Chest X Ray

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When:

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Where:

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Have you recently had a Chest CT (cat scan)

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When:

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Where:

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Have you recently been hospitalized?

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When:

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Where:

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Have you had exposure to chemicals

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Type:

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Have you recently traveled outside of the country:

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Where:

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Have you had the Flu Vaccine(s)

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Please list the last month / year you had your last Flu Vaccine

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Have you had the Pneumonia Vaccine

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Which one

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Please list the last month / year you had your last Pneumonia Vaccine

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Review of Symptoms

Please check any symptoms you are CURRENTLY experiencing below:

General

None

Fatigue (easily tired)

Malaise (generally unwell)

Fevers

Chills

Night Sweats

Recent Weight Loss

Recent Weight Gain

Gastrointestinal

None

Abdominal Pain

Constipation

Diarrhea

Heartburn

Loss of Appetite

Nausea

Vomiting

Musculoskeletal

None

Back Pain

Joint Pain

Joint Swelling

Muscle Weakness

ENT

None

Earache

Hoarseness

Nasal Congestion

Post Nasal Drainage

Sinus Pressure

Sore Throat

Genitourinary

None

Increase in Urination

Urination During the Night

Hematologic / Lymphatic

None

Easy Bleeding

Easy Bruising

Swollen Lymph nodes/glands

Respiratory

None

Cough

Shortness of Breath

Coughing up Blood

Pain with Breathing

Wheezing

Known TB Exposure

Psychological

None

Anxiety

Depression

Immunologic

None

Seasonal Allergies

Contact Allergies

Food Allergies

Inhalation Allergies

Dermatologic

None

Hives

Rash

Itching

Skin Lesions

Sleep

None

Insomnia

Wake up Gasping/Choking

Sleepiness during the Daytime

Restless Sleep

Snoring

Cardiovascular:

None

Chest Pain

Claudication (leg pain with activity)

Edema (lower leg swelling)

Palpitations

Orthopnea (shortness of breath when lying down)

Neurological

None

Dizziness

Numbness in Hands / Feet

Weakness in One / Both Arms / Legs

Abnormal Gait (unusual walking)

Headache

Memory Loss

Seizures

Tremors

Personal Medical History

Pulmonary:

Allergies

Alpha 1 Antirypsin

Asbestosis

Asthma

RecurrentBronchitis

COPD

Emphysema

Lung Nodules

Pneumonia

Pulmonary Embolism

Pulmonary Fibrosis

Sarcoidosis

Sleep Apnea

Valley Fever (Coccidioidomycosis)

Rheumatologic

Lupus

Rheumatoid Arthritis

Cardiovascular:

Anemia

Atrial Fibrillation

Blood Clots / DVT

Chest Pain (Angina)

Congestive Heart Failure

Coronary Artery Disease

Elevated Cholesterol

High Blood Pressure

Heart Attack (MI)

Murmur / Heart Valve Disease

Stroke

Gastrointestinal

Acid Reflux (GERD)

Hepatits

Genitourinary

Kidney Stones

Chronic Kidney Disease

Neurologic / Psychological

Anxiety

Bipolar Disorder

Dementia

Depression

Insomnia

Restless Leg Syndrome

Metabolic

Type 1 Diabetes

Type 2 Diabetes

Hyperthyroidism

Hypothyroidism

Musculoskeletal

Fibromyalgia

Osteoarthritis

Other

Cancer

Cancer Type:

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HIV / AIDS

Tuberculosis

Immunoglobulin Deficiency

Additional Medical History

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Surgical History

Pulmonary

Bronchoscopy

Year:

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Left Lobectomy

Year:

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Right Lobectomy

Year:

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Lung Biopsy

Year:

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Lung Surgery

Year:

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Tonsillectomy

Year:

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Adenoidectomy

Year:

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Tracheostomy

Year:

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Sinus Surgery

Year:

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Cardiovascular

CABG / Open Heart Surgery

Year:

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Cardiac Catheterization

Year:

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Cardiac Stent

Year:

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Pacemaker

Year:

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Gastrointestinal

Appendix Removal

Year:

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Gall Bladder Removal

Year:

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Gastric Bypass

Year:

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Hernia Repair

Year:

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Genitourinary

Dialysis

Year:

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Kidney Stone Removal

Year:

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Kidney Removal

Year:

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Muskulosketal

Back Surgery

Year:

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Left Hip Replacement

Year:

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Right Hip Replacement

Year:

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Left Knee Replacement

Year:

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Right Knee Replacement

Year:

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Neck Surgery

Year:

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Left Rotator Cuff Repair

Year:

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Right Rotator Cuff Repair

Year:

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Female

C-Section (Cesarean)

Year:

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Hysterectomy

Year:

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Tubal Ligation

Year:

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Male

Prostate Surgery

Year:

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Other

Cataract Surgery

Year:

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LASIK

Year:

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Lymph Node Biopsy

Year:

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Mastectomy

Year:

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Thyroidectomy

Year:

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Additional Surgery History

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Family History

Pulmonary

Alpha 1 Antitrypsin

Father:

Mother:

Brother:

Sister

Asthma

Father:

Mother:

Brother:

Sister:

COPD

Father

Mother

Brother

Sister

Emphysema

Father

Mother

Brother

Sister

Pulmonary Fibrosis

Father

Mother

Brother

Sister

Pulmonary Hypertension

Father

Mother

Brother

Sister

Sarcoidosis

Father

Mother

Brother

Sister

Sleep Apnea

Father

Mother

Brother

Sister

Cancer:

Breast Cancer

Father

Mother

Brother

Sister

Colon Cancer

Father

Mother

Brother

Sister

Lung Cancer

Father

Mother

Brother

Sister

Other Cancer

Specify Cancer:

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Father

Mother

Brother

Sister

Cardiovascular

Coronary Artery Disease

Father

Mother

Brother

Sister

Hypertension

Father

Mother

Brother

Sister

Venous Thrombosis

Father

Mother

Brother

Sister

Rheumatologic:

Rheumatoid Arthritis

Father

Mother

Brother

Sister

Lupus

Father

Mother

Brother

Sister

Neurological:

Social

Alzheimer's

Father

Mother

Brother

Sister

Dementia

Father

Mother

Brother

Sister

Endocrine:

Diabetes

Father

Mother

Brother

Sister

Alcoholism

Father

Mother

Brother

Sister

Drug Abuse

Father

Mother

Brother

Sister

Additional Family History

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Social History

Do you use Tobacco?

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Type of Tobacco

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Overall Daily Average Packs / Pipe / Can

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Total Years Used

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Date Quit

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Do you drink Alcohol

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How Much Beer / Glasses / Drinks

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Date Quit

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How Often

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Do you drink Caffeine

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Type of Caffeine

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How Many Cups / Ounces

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Do you use Recreational Drugs

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Type

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Date Quit

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Do you exercise

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Type of Exercise

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How Often

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Occupation

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Marital Status

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Number of Children (Specify number of Sons / Daughters)

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Do you have Pets

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Type

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Medication Information

Name

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Birth Date

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Pharmacy Information

Name:

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Address

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Phone

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Please list all food and drug allergies and the type of reaction

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Please list all medications and INHALERS

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