Pulmonary Function Test Questionnaire
Please complete this questionnaire to help us assess your respiratory health prior to your Pulmonary Function Test.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently have any of the following respiratory symptoms? (Select all that apply)
*
Cough
Shortness of breath
Wheezing
Chest tightness
None of the above
Other
Have you ever been diagnosed with any of the following conditions?
*
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Pneumonia
Tuberculosis
None of the above
Other
Do you currently smoke or have you smoked in the past?
*
Current smoker
Former smoker
Never smoked
If you are a current or former smoker, please indicate the number of years you have smoked and the average number of cigarettes per day.
Are you currently taking any medications? Please list them.
Have you previously undergone a Pulmonary Function Test?
*
Yes
No
Family history of respiratory diseases (e.g., asthma, COPD, lung cancer)?
*
Yes
No
Unknown
On a scale of 1 to 10, how would you rate your current level of physical activity? (1 = Not active at all, 10 = Very active)
Not active at all
1
2
3
4
5
6
7
8
9
Very active
10
1 is Not active at all, 10 is Very active
Please indicate if you have been exposed to any occupational or environmental factors that may affect your lung health (e.g., dust, chemicals, fumes).
Submit Questionnaire
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