Dyspnea Diagnostic Evaluation Form
Use this form to document shortness of breath symptoms, relevant context, prior evaluation, and follow-up needs.
Patient & Symptom Overview
Full Name
*
First Name
Middle Name
Last Name
Age
*
Sex at Birth / Gender Identity
*
Please Select
Female
Male
Intersex
Non-binary
Prefer to self-describe
Prefer not to say
Primary Symptom Description
*
Symptom Onset Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptom Duration
Symptom Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Shortness of Breath Pattern
*
Constant
Intermittent
Worse with Activity
Worse at Rest
Unclear
Associated Factors & Context
Known triggers or aggravating factors
Exertion
Lying flat
Cold air
Anxiety/Stress
Allergens
Unknown
Other
Associated symptoms
Cough
Wheezing
Chest pain
Fever
Leg swelling
Dizziness
Palpitations
None
Relevant medical history related to breathing problems
Current medications or inhalers
Smoking or vaping exposure status
Never used
Former user
Current smoker
Current vaper
Secondhand exposure
Other
Diagnostic Review & Follow-up
Prior evaluation/testing already completed
Pulse oximetry
Chest X-ray
ECG
Spirometry
Blood tests
None
Other
Notes for clinician/reviewer
Preferred follow-up method or next-step visit type
Phone call
Video visit
In-person visit
Home monitoring
No follow-up needed yet
Other
Submit
Should be Empty: