Shortness of Breath Chief Complaint Intake Form
Please complete this form to help us better understand your shortness of breath symptoms. Do not include sensitive personal information.
Age
*
Sex
*
Male
Female
Prefer not to say
Other
How long have you been experiencing shortness of breath?
*
Please Select
Less than 1 hour
1–24 hours
1–7 days
More than 1 week
How severe is your shortness of breath?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
When does your shortness of breath occur?
*
At rest
With exertion
While lying down
At night
Other
Which symptoms do you also have?
*
Chest pain
Cough
Wheezing
Fever
Swelling in legs
None of the above
Other
What makes your shortness of breath better or worse?
*
Do you have any history of the following conditions?
*
Asthma
COPD (Chronic Obstructive Pulmonary Disease)
Heart disease
Pneumonia
Blood clot in lung
None of the above
Other
Please list any medications you are currently taking.
*
Do you have any medication allergies?
*
Yes
No
Not sure
Submit
Should be Empty: