Pulmonary and Medicine Associates - PMA

Pulmonary and Medicine Associates, PLLC

27472 Schoenherr, Suite 100

Warren MI 48088

Phone: 586-751-8844

RESPIRATORY HISTORY

Name *

Date of Birth *

1. SHORTNESS OF BREATH

For 1 month

For 1 year

Over 1 year

Daily

Weekly

Monthly

Severe

Moderately

Mild

AGGRAVATED BY

Climbing stairs

Walking on level ground

Walking up a slight hill

Walking with people your own age

Lying down or sleeping in bed

2. COUGH

Deep in chest

Clearing the throat only

For 1 month

For 1 year

Over 1 year

CONDITION OF:

When lying down

When arising in the morning

At night

During the day

ACCOMPANIED BY:

Green, yellow, or discolored phlegm

Bloody or blood-streaked phlegm

Heavy phlegm

Coughs phlegm on arising

Coughs phlegm 3 weeks at a time

Spasms of cough

3. WHEEZING

For 1 month

Daily

Weekly

Monthly

Wheezes on exertion

Severe

Moderately severe

Mild

Coughs on exertion

4. SMOKING

Never smoked

Cigarettes

Cigar

Pipe

Inhale

Do not inhale

½ pack per day

2 packs

More than 2 packs

Age started

Age stopped

5. OTHER SYMPTOMS

Exertional chest pain

Chest pain with deep breathing

Diarrhea

Sneezing

Difficulty in swallowing

Hoarseness

Leg swelling

Loss of appetite

Weight loss

Fever

Chills

Night sweats

6. COLDS

Have a cold now

Number of colds per year:

More winter colds

Chest colds

Difficulty in shaking colds

7. PAST HISTORY OF:

Drug allergy

Other allergies

Skin test

Chest operation

Chest injury

Broken ribs

Asthma

Family history of asthma

Bronchitis

Bronchiectasis

Emphysema

Blood clots

Pneumonia

Fungus disease of the lung

Sarcoidosis

Sinus trouble

Hay fever

Pleurisy

Lung cancer

Other cancer

Collapsed lung

Tuberculosis

TB skin test

Year TB skin test:

Year of last Chest Xray:

8. SLEEP

Wake up feeling tired or not rested

Fall asleep while watching TV

Fall asleep while driving

Nap during the day

Difficulty falling asleep

Snoring

Told by bed partner that you have difficulty breathing at night.

Fall out of bed during sleep

Walk during sleep

Have unusual movements during sleep

Wake up with headache

Feel unable to move when waking up

Memory problems

Problem with depression

Get up at night to urinate