Respiratory Therapy Appointment Pre-screening Form
Please complete this form to help us prepare for your upcoming respiratory therapy appointment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
Are you currently experiencing any of the following symptoms?
*
Shortness of breath
Cough
Wheezing
Chest tightness
Fever
None of the above
Other
Have you been diagnosed with any of the following conditions?
*
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Sleep apnea
Pneumonia (past 12 months)
None of the above
Other
Have you recently (past 14 days) had close contact with anyone diagnosed with a respiratory infection?
*
Yes
No
Not sure
Are you currently taking any medications related to respiratory conditions?
*
Yes
No
If yes, please list your current respiratory medications (leave blank if not applicable).
Is there anything else you would like your respiratory therapist to know before your appointment?
Submit
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