Pneumonia Chief Complaint Form
Please provide details about your symptoms and relevant medical history to help assess for possible pneumonia.
Full Name
*
First Name
Last Name
Age Group
*
Please Select
Under 18
18-29
30-49
50-64
65 and above
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which of the following symptoms are you experiencing?
*
Cough
Fever or chills
Shortness of breath
Chest pain
Fatigue
Other
How would you rate the severity of your symptoms?
*
Mild
Moderate
Severe
Have you recently been exposed to anyone with respiratory illness?
*
Yes
No
Not sure
Do you have any of the following conditions?
*
Asthma
COPD (Chronic Obstructive Pulmonary Disease)
Diabetes
Heart disease
None of the above
Do you smoke or have a history of smoking?
*
Yes, currently smoke
Yes, but quit
No
Have you traveled in the past 30 days?
*
Yes
No
Please describe any other symptoms or relevant information.
Submit
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