PULMONARY HEALTH QUESTIONNAIRE
Patient Name
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
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Reason for Visit
Past History
Have you ever had
Asthma
Emphysema
Bleeding Problems
Stroke
Tuberculosis
Pneumonia
Kidney Problems
Ulcers
Seizures
Diabetes
Liver Problems
Arthritis
Heart Attack
High Blood Pressure
Heart Problems
Blood Clots
Cancer
Thyroid Problems
Have you ever had Surgery?
Yes
No
Type of surgery
Date
-
Month
-
Day
Year
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Type of surgery
Date
-
Month
-
Day
Year
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Type of surgery
Date
-
Month
-
Day
Year
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Type of surgery
Date
-
Month
-
Day
Year
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Social History
Do you use tobacco?
Yes
No
What Type?
Cigarettes
Chew
Pipe
Cigars
#/Day
How many years
When did you quit?
-
Month
-
Day
Year
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Do you drink alcoholic beverages?
Yes
No
How many per week?
Have you ever used marijuana or any other illicit drug?
Yes
No
Do you tolerate physical exercise well?
Yes
No
Have you traveled/lived abroad?
Yes
No
Do you have trouble sleeping?
Yes
No
Do you have pets?
Yes
No
What kind of pets?
List of Medications & Dosage
Allergies
Are you allergic to any medications?
Yes
No
Which medications?
Other allergies
Family History
Rows
Age (if living)
Age at Death
State of Health/Cause of Death
Mother
Father
Brother/Sister
Brother/Sister
Brother/Sister
Children
Children
Spouse/Partner
Review of Systems – Please check all that apply
General
Weight changes
Sleeping Problems
Loud Snoring
Fevers/Chills/Sweats
Skin
Skin Rash
Itching
New Skin Marks/Spots
Head/Eyes/ Ears/Nose/Throat
Visual Problems/Changes
Itching Eyes/Nose
Nose Bleeds
Drainage from Nose
Sinus Infections
Hoarseness
Sore Throats
Headaches
Respiratory
Coughing
Wheezing
Shortness of Breath
Bronchitis
Frequent Colds
Coughing Up Blood
Cardiovascular
Chest Pain
Heart Attack
Heart Murmur
Palpitations
Irregular Heart Beat
Short of Breath w/ Walking
Dizziness
Swelling of Feet/Ankles
Gastrointestinal
Nausea/Vomiting
Vomiting Blood
Difficulty Swallowing
Heartburn/Indigestion
Abdominal Pain
Constipation
Diarrhea
Bloody/Black Stools
Genitourinary
Pain with Urination
Frequent Urination
Blood in Urine
Kidney Stones
Musculoskeletal
Joint Pain/Swelling
Back Pain
Muscle Pains/Aches
Neurological
Numbness
Tingling
Weakness/Paralysis
Tremors
Seizures
Psychological
Depression
Anxiety/Panic Attacks
Other Medical Problems Not Listed
Patient Signature: ____________________________________________ Date: ________________
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