Pulmonary Function Test Intake Form
Please complete this form to provide essential information before your pulmonary function test. All responses are confidential and used only for your medical care.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Do you currently have any of the following symptoms? (Select all that apply)
*
Cough
Shortness of breath
Wheezing
Chest pain
None of the above
Do you have a history of any of the following? (Select all that apply)
*
Asthma
COPD (Chronic Obstructive Pulmonary Disease)
Emphysema
Pulmonary fibrosis
No relevant history
Are you currently taking any medications? If yes, please list them.
Do you currently smoke or have you smoked in the past?
*
Never smoked
Current smoker
Former smoker
Is there any possibility you are currently pregnant?
*
Yes
No
Not applicable
Have you had a pulmonary function test before?
Yes
No
Not sure
Referring Clinician Name
Submit
Should be Empty: