Center for Respiratory and Sleep Disorder

Patient INTAKE

Gilbert Respiratory Associates



   M   F

Reason for the visit:


  Follow up from Hospital.
  Cough    Sputum Production   Shortness of Breath   Sleep Disorder/Apnea 
 Abnormal CXR (mass, nodule …)
Other: 

General Medical History:


  High Blood Pressure    Heart condition  High Cholesterol  
  Diabetes    Renal failure  Thyroid  
  Stroke    Seizure  Restless leg syndrome   Parkinson disease  
 Back pain    Arthritis  
 Depression    Anxiety     Bipolar  

Pulmonary History:

Valley fever   COPD    Asthma    Pneumonia   TB  Pulmonary Embolism 
 Previous pulmonary testing:  

Medication: (if you have a list, please attach)

     
     
     
     

Drug Allergies:

Social History:

 Tobacco: How many years:  Packs per day:   Quit: 
 Environmental Hazard / Exposure/Pets: 
      Length of residence in AZ:  

Family History: (check all that apply)

Family Cancer/Type Lung Disease/Type Heart Disease/Type High Blood Pressure Diabetes
Mother
Father
Siblings

REVIEW OF SYSTEMS: (Check all that apply)

Endocrine system
  Weight Gain    Weight Loss  Poor appetite   Fever    Night sweats

ENT
  Congested Sinuses    Runny nose  

Cardiovascular
 Chest Pain   Palpitation  

Respiratory
  Cough    Sputum Production  Shortness of Breath   Snoring  

Gastrointestinal
  Heart Burn    Abdominal Pain Indigestion  

Musculoskeletal
  Back Pain    Joint Pain Arthritis  

Psychiatry:
  Depression  Anxiety Bipolar  

Genitourinary
  Prostate Problems  Blood in Urine Bipolar  

Skin
  Skin Cancer   Dry Skin 

Neurology
  Insomnia  Head Ache  Dizziness  

Hematology
  Easy Bruising   Blood Clots  Cancer:  

Eyes
  Blurred Vision   Glaucoma  Cataract  

Immunology/Allergy
  Environmental Allergies   Eczema  Hay fever    Food allergy: 

  HIPPA Privacy act was reviewed