Pneumothorax Diagnostic Evaluation Form
Use this form to document symptoms, risk factors, exam findings, imaging, and management details for suspected pneumothorax.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
*
Sex at Birth
*
Female
Male
Intersex
Prefer not to say
Other
Preferred Contact Information
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Complaint and Symptom Details
Primary reason for evaluation
*
Please Select
Sudden chest pain
Shortness of breath
Trauma-related symptoms
Incidental finding
Follow-up assessment
Other
Symptom onset date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Duration of symptoms
Chest pain present?
*
Yes
No
Chest pain location
Please Select
Left chest
Right chest
Central chest
Diffuse
Back
Shoulder
Other
Pain severity
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Shortness of breath present?
*
Yes
No
Symptoms, triggers, or relieving factors
Risk Factors and Relevant History
Recent trauma or injury
*
No
Yes
Unsure
Recent surgery or procedure
*
No
Yes
Unsure
Mechanical ventilation or positive-pressure therapy
*
No
Yes
Unsure
Smoking history
*
Never
Former
Current
Unsure
Vaping history
Never
Former
Current
Unsure
Known lung disease
Asthma
COPD (chronic obstructive pulmonary disease)
Emphysema
Pulmonary fibrosis
Bronchiectasis
Cystic fibrosis
Interstitial lung disease
Other
Prior pneumothorax
No
Yes
Unsure
Other relevant respiratory or cardiac history
Clinical Assessment and Diagnostics
Respiratory Rate (breaths/min)
Heart Rate (beats/min)
Oxygen Saturation (%)
Blood Pressure
Temperature
Physical Exam Findings
Decreased breath sounds
Hyperresonance
Tracheal deviation
Asymmetric chest rise
Respiratory distress
Subcutaneous emphysema
Other
Imaging Requested or Completed
Chest X-ray
Chest ultrasound
CT chest
Repeat imaging
Other
Imaging Interpretation / Clinician Impression
Management and Follow-Up
Immediate management actions taken
Observation
High-flow oxygen
Needle decompression
Chest tube insertion
Analgesia provided
Other
Oxygen therapy status
Not given
Nasal cannula
Non-rebreather mask
High-flow oxygen
Other
Management decision
*
Observation and monitoring
Intervention performed
Intervention planned
Escalated to senior review
Other
Referral or transfer disposition
Please Select
Discharged with advice
Admitted for observation
Transferred to emergency department
Referred to respiratory specialist
Referred to thoracic surgery
Other
Follow-up plan and clinician notes
Submit Evaluation
Should be Empty: