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Physicians
Jed bayasi, MD
Virginia Rowland, MD
Patients Information
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Information Form
Patient Intake
Release Of Records
Hippa
Insurance
Health Education
Health Topics
Patient Health Series
Services
Respiratory
Lung Cancer Screening
Lung Nodule
Sleep Disorder
Appointments
Contact/Map
Email:Grafax@gmail.com
Phone:480-917-0933
Fax:480-917-8866
Address:3491 S Mercy Rd. Suite 103,Gilbert AZ.85297
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Gilbert Respiratory Associates | Center for Respiratory and Sleep Disorder
Home
Physicians
Jed bayasi, MD
Virginia Rowland, MD
Patients Information
New Patient
Forms
Information Form
Patient Intake
Release Of Records
Hippa
Insurance
Health Education
Health Topics
Patient Health Series
Services
Respiratory
Lung Cancer Screening
Lung Nodule
Sleep Disorder
Appointments
Contact/Map
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Patient Intake
Sex
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 add)
Drug Allergies:
Social History:
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:
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