New Patient

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Patient Demographics

Multiple Choice
Mailing Address
Marital Status
Race/Ethnicity
Field
Preferred Method of Contact

Emergency Contact

Notice of Privacy Practices Consent and Acknowledgement

Our Notice of Privacy Practices provides information about how Independent Lung Associates P.A. may use and disclose protected health information about you. I consent to the use or disclosure of my protected health information by Independent Lung Associates P.A. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Independent Lung Associates P.A. I acknowledge that I have been provided with the Practice’s Notice of Privacy Practices that provides a description of Protected Health Information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this statement. I understand that the Practice reserves the right to change its Notice of Privacy Practices that will be effective for the health information the Practice already has about me, as well as any they receive in the future. I understand that I may obtain a copy of the current Notice in effect upon request. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that the Practice is not required to agree to my requested restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

List of Names with whom we can share medical information

PERSONAL MEDICAL
HISTORY

Review of Symptoms (CURRENT symptoms only)

General
Respiratory
Musculoskeletal
Skin
Cardiovascular
Neurological
HEENT
Gastrointestinal
Psychiatric
Neck

Allergies and Reaction (include environmental allergies, medication and/or food allergies

Immunizations:

Smoking

Do you smoke?
Have you ever smoked?
Any significant exposure to second hand smoke?

Alcohol Use

Do you drink alcohol?
previous use

Drug Use

Do you use illicit drugs?
previous use
Do you have any pets?

Immediate Family History

Please check if any immediate blood relatives have had any of the following

Is your motherLivingDeceased

Past Medical History (Please check any that apply)

Prior Testing

Surgical History

Lung Surgery
Heart Surgery
Tonsillectomy
Sleep Apnea Surgery

PULMONARY
QUESTIONNAIRE

Cough

Do you usually cough first thing in the morning?
Do you usually cough after going to bed at night
Do you usually cough after eating or drinking?
Do you cough every day for > 6 months?
How long have you had this cough? ______# of Days
Do you bring up phlegm or sputum when you cough?
Have you ever coughed up blood?
Do you wake at night with an acid sour taste in your mouth?
Do you wake up with a sore throat in the morning?
Do you experience hoarseness when talking?
Do you experience burning chest pain?

Asthma/COPD/Bronchitis

Have you ever noticed whistling or wheezing in your chest?
If yes, how frequent?
Colds Only
Is your wheezing more common during a particular season?
Season(s)? Is your wheezing related to any of the following? (Check all that apply)
Have you ever gone to the Emergency Room for Asthma?
Have you ever hospitalized for Asthma?
Have you ever gone to the Emergency Roomfor COPD?
Have you ever hospitalized for COPD?

Medications

Please list all medications (Prescribed or Over the Counter) that you are currently taking. You may attach a list.

SLEEP QUESTIONARE

It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can



Describe your main problem(s) in your own words, including when and how this began and what treatment you have received for this in the past:

SLEEP HISTORY

Do you experience any of the following at night?
Do you have feelings of depression/anxiety?
Do you have feelings of anxiety or racing thought?
Do you have hallucinations upon falling asleep or upon waking?
Do you have crawling sensations in your legs?
Do you work split shifts or variable shifts?
Do you usually drink caffeine within two hours of going to bed?
Awaken from sleep short of breath or gasping for air
Experience crawling and aching feelings in your legs
Have you been told you snore at night?
Sweat excessively at night
Notice your heart pounding or beating irregularly during the night
Fall asleep during the day
Fall asleep involuntarily or while driving
Fall asleep or lose muscle tone when laughing or crying
Feel unable to move (paralyzed) when waking or falling asleep
Experience vivid dreamlike scenes upon awakening or falling asleep
Remember your dreams
Do any of your family members have sleep apnea?

Epworth Sleepiness Scale


How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired. This refers to your usual way of life in recent times. Even if you have not done some of these activities recently, try to work out how they would affect you.


Use the following scale to choose the most appropriate number for each situation.



0 = would never doze
1= slight chance of dozing
2= moderate chance of dozing
3= high chance of dozing

Situation

Chance of Dozing

Sitting and reading
Watching TV
Sitting, inactive in a public place (theatre, meeting, etc)
As a passenger in a car for an hour without break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
$0.00