Bronchitis Diagnostic Evaluation Form
Please complete this form to assist in the assessment and diagnosis of bronchitis symptoms.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Presenting Symptoms (Check all that apply)
*
Cough
Sputum Production
Shortness of Breath
Chest Discomfort
Fever
Wheezing
Other
Duration of Symptoms (in days)
*
Rate the severity of your cough
*
None
0
1
2
3
4
5
6
7
8
9
Severe
10
0 is None, 10 is Severe
Do you smoke or have a history of smoking?
*
Current smoker
Former smoker
Never smoked
Relevant Medical History (select all that apply)
Asthma
COPD (Chronic Obstructive Pulmonary Disease)
Heart Disease
Diabetes
Immunosuppressive Condition
None of the above
Please indicate any additional symptoms or relevant information
Physical Exam Findings (if applicable)
Rows
Normal
Abnormal
Breath sounds
1
2
Wheezing
3
4
Rales/Crackles
5
6
Use of accessory muscles
7
8
Physician's Notes / Assessment
Submit Evaluation
Should be Empty: