Personal Information

Recent Medical History

Have you been admitted to the hospital, had surgery, or been evaluated in the emergency room or urgent care since your last visit? If yes, please specify.*

Have you been to your PCP or a specialist since your last visit? If yes, please specify.*

Have there been any changes to your medication since your last visit? If yes, please specify.*

Have there been any problems with your inhalers/respiratory medicines since your last visit?*

Do you have any NEW drug allergies? If yes, please specify.*

Do you have any NEW environmental and/or food allergies? If yes, please specify.*

Did you receive the flu vaccine this year?*

Have you received pneumonia vaccine and if so when?*

Do you currently smoke or chew tobacco?*

Have you quit smoking recently? If so when?*

Current Medical Condition

Do you feel sick today? If yes, specify symptom/problem.*

Are you experiencing any chest pain?*

Is your shortness of breath getting worse?*

Have you coughed up blood since your last visit?*

Do you currently have a cough or sputum expectoration? If so, what color is phlegm?*

Do you have leg pain or cramps at rest or with activity/excercise?*

Do you have swelling in your leg(s)?*

Do you have foot ulcers or sores on your legs that are not healing?*

Do you have skin color changes or hair loss on your legs?*

Do you need any of your respiratory medications refilled today? If yes, please specify.*

Sleep History

Do you have concerns about your sleep that the doctor needs to evaluate today?*

Do you use CPAP? If so, how frequently?*
no yes: 1 2 3 4 5 6 7 nights a week; 1 2 3 4 5 6 7 8 9 10 11 12 hours a night

Do you use oxygen? If yes, when and what is your liter flow?*
no yes - How many hours? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 When? 24 hr at night w/activity Liter Flow:

Have there been any problems with your CPAP/BPAP/ASV device since last visit? If yes, please specify.*

Who is your DME (Durable Medical Equipment) Co?:

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