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Conditions
Sleep Medicine
Our Physicians
New Patients
Patient Resources
Contact
Call
(626) 486-0181
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New Patient History and Review of Systems
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New Patient History and Review of Systems
Name
Date of birth
Reason to visit
Past Medical History
Have you ever been diagnosed with?
Asthma
COPD
Bronchitis
Pneumonia
Tuberculosis
Positive TB Skin test (PPD)
Other medical illnesses?
Past surgical history
Lung Surgery
Heart Surgery
Other Surgeries
Allergies
Penicillin
Sulfa Drug
lodine
Aspirin
Social History
Who do you live with?
Do/did you smoke?
Yes, currently
No, I have never smoked
Yes, but I quit
When did you quit?
Do/did you drink alcohol?
No, never
Daily
Weekly
Less frequently
Do/did you use other drugs?
No, never
yes, currently
Yes, but in the past
If so, what type?
Occupational History
Occupational History
Working
Retired
Unemployed
Disabled
What is/was your main job?
Were you ever regularly exposed to:
Coal dust
Chemical fumes
Silica dust
Asbestos
Paint sprays
Caged Birds
Family History
Asthma
Emphysema
Lung cancer
Other lung disease
Other cancer
Immunization Status
Current Medication List
Medication
How Strong
How Often
Select Other Side Effects
Fever
Yes
No
Chills
Yes
No
Weight Loss
Yes
No
Malaise/Fatigue
Yes
No
Sweats
Yes
No
Difficulty swallowing
Yes
No
Heart burn
Yes
No
Nausea or vomiting
Yes
No
Abdominal pain
Yes
No
Diarrhea
Yes
No
Constipation
Yes
No
Bloody stools
Yes
No
Black tarry stools
Yes
No
Skin Rash
Yes
No
Eczema or dermatitis
Yes
No
Headaches
Yes
No
Hearing Loss
Yes
No
Ringing in the ears
Yes
No
Ear pain or discharge
Yes
No
Nose bleeds
Yes
No
Sinus Congestion
Yes
No
Sore Throat
Yes
No
Blurred or double vision
Yes
No
Sensitivity to light
Yes
No
Eye pain or discharge
Yes
No
Eye redness
Yes
No
Chest pain
Yes
No
Palpitations
Yes
No
Shortness of breath lying flat
Yes
No
Calf pain
Yes
No
Leg swelling
Yes
No
Awakening at night short of breath
Yes
No
Discomfort passing urine
Yes
No
Urgent or frequent urination
Yes
No
Blood in the urine
Yes
No
Kidney pain
Yes
No
Muscles aches
Yes
No
Neck or back pain
Yes
No
Joint pain
Yes
No
Falls
Yes
No
Anemia
Yes
No
Swollen lymph nodes (glands)
Yes
No
Easy bruising
Yes
No
Seasonal allergies
Yes
No
Allergies to animals
Yes
No
Hay fever
Yes
No
Risk of HIV
Yes
No
Chronic prednisone therapy
Yes
No
Cough
Yes
No
Coughing up blood
Yes
No
Wheezing
Yes
No
Thyroid problems
Yes
No
Diabetes
Yes
No
Snoring or irregular heartbeat
Yes
No
Sleepiness during the day
Yes
No
Sudden awakenings from sleep
Yes
No
Headaches on awakening
Yes
No
Numbness or tingling
Yes
No
Tremor
Yes
No
Speech change
Yes
No
Localized weakness
Yes
No
Seizures
Yes
No
Passing out, loss of consciousness
Yes
No
Dizziness
Yes
No
