PATIENT HISTORY

METROPLEX PULMONARY & SLEEP CENTER, P.A
4833 Medical Center Drive, Suite 6B McKinney, Texas 75069
Phone: 972- 838-1892 Fax: 972-838-1896 or 972-954-6030
PATIENT HISTORY FORM
Name*
Phone*
Date of birth*
Age*
Describe the current medical problem or reason for today’s visit:
Have you had any recent CT Scans, x-rays or lab tests, relating to this problem?
- Yes
- No
If yes, when and where were those done?
Who is your primary care physician?
Who is your referring physician for today’s visit?
Have you ever been diagnosed with the following?
- asthma
- chronic bronchitis
- emphysema
- pneumonia
- heart attack
- stroke
- hypertension
- diabetes
- sleep apnea
- kidney disease
- gastric ulcers
- hepatitis
- thyroid disease
- high cholesterol
- congestive heart
- tuberculosis
Past Surgical History (If you have a list we can make a copy):
Other Hospitalizations:
Are you allergic to any medications?
- Yes
- No
If yes please write the name of the Medication(s
Current Medications: Please list all medications you are currently taking. We can also make a copy of your medication list if you have it with you.
Current Medications:
Are you using:
- Oxygen
- CPAP
- Nebulizer
Do you smoke (current smoker)?
- Yes
- No
how many packs a day?
Ex-smoker:
Number of years smoked
how many packs per day?
Do you consume alcohol on a regular basis?
- Yes
- No
If yes-how much?
Do you have any history of family diseases?
- Yes
- No
Have you ever had the flu vaccine?
- Yes
- No
Have you ever had the pneumonia vaccine?
- Yes
- No
Occupation:
Are you married?
- Yes
- No
Do you have any children?
- Yes
- No
Do you have pets at home?
- Yes
- No
Have you been exposed to dust, fumes, or asbestos?
- Yes
- No
Do you snore?
- Yes
- No
Do you stop breathing at night?
- Yes
- No
Do you have difficulty falling asleep?
- Yes
- No
Do you have difficulty staying asleep?
- Yes
- No
What time do you go to bed?
And wake up?
Time you usually fall asleep?
Number of times you wake up at night?
Do you sleep walk?
- Yes
- No
Do you talk while sleeping?
- Yes
- No
Do you have nightmares/abnormal dreams?
- Yes
- No
Do you feel tired in the morning?
- Yes
- No
Do you have difficulty staying awake during the daytime?
- Yes
- No
Do you have restless leg symptoms?
- Yes
- No
Do your legs ache at night?
- Yes
- No
Do you feel muscle weakness while laughing or crying?
- Yes
- No
Do you have Fevers or Chills:
- Yes
- No
Do you sweat at night?
- Yes
- No
Do you get short of breath?
- Yes
- No
with exertion (exercise)
- Yes
- No
When did you first notice shortness of breath?
- Days
- Weeks
- Months
- Years
Has the shortness of breath gotten worse over time?
- Yes
- No
If so, has it gotten worse:
- slowly
- suddenly
If so, how much exertion does it take: (circle all that apply?)
- walking slowly
- walking quickly
- climbing up a slope/ hill
- climbing stairs
Does anything else make you short of breath?
Do you wake up at night short of breath?
- Yes
- No
Do your feet swell?
- Yes
- No
Do you feel shortness of breath when you first lie down at night?
- Yes
- No
When lying down do you prop your head up to breath comfortably?
- Yes
- No
Do you wake up wheezing at night?
- Yes
- No
Do you cough?
- Yes
- No
How long have you been coughing for?
Does anything cause you to cough or worsen it?
Is cough worse at certain times of the day?
Is cough worse at night?
Does it wake you up at night?
Do you bring up sputum?
- Yes
- No
What color is your sputum:
- Circle one: clear
- white
- gray
- yellow
- green
On average how much sputum do you cough up during a day?
Have you ever noticed blood in your sputum?
- Yes
- No
Do you have pain/discomfort in your chest?
- Yes
- No
If so, what area of chest?
What type of pain:
- sharp
- dull
- stabbing
- constant
- intermittent
Does pain shift to another part of your body?
- Yes
- No
Is pain worse with exercise?
- Yes
- No
Is pain worse with deep breathing?
- Yes
- No
Do you wheeze?
- Yes
- No
What makes you wheeze?
Have you ever been exposed to Tuberculosis?
- Yes
- No
Do you suffer from:
- headaches
- seizures
- passing out spells
- dizziness
Do you experience:
- nausea
- vomiting
- diarrhea
- reflux
Do you experience:
- arthritis
- muscle aches
- Third Choice
Did you notice:
- weight loss
- weight Gain
- fatigue
Print Patient’s Name:
Signature of Patient:
Date:*
MM slash DD slash YYYY
EPWORTH sleepiness scale Questionnaire
PRINT IN CAPITAL LETTERS-STAY WITHIN THE BOX
Name*
First Middle Last
Weight

Pounds
Age

Years
Gender
- Male
- Female
Height (Feet)
Inches
Neck Size (Inches)
Date
COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION- ANSWER ALL QUESTIONS
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 things recently, try to work out how they would have affected you. Use the following scale to mark the most appropriate box for each situation. (M.W. Johns, Sleep 1991)

0 = would never doze
1 = slight chance of dozing
2 = moderate change of dozing
3 = high chance of dozing
Sitting and reading
- 0
- 1
- 2
- 3
Watching TV
- 0
- 1
- 2
- 3
Sitting, inactive, in a public place(theater, meeting, etc)
- 0
- 1
- 2
- 3
As a passenger in a car for an hour without a break
- 0
- 1
- 2
- 3
Lying down to rest in the afternoon when circumstances permit
- 0
- 1
- 2
- 3
Sitting and talking to someone
- 0
- 1
- 2
- 3
Sitting quietly after lunch without alcohol
- 0
- 1
- 2
- 3
In a car, while stopped for a few minutes in traffic
- 0
- 1
- 2
- 3
- Epworth Score
  TOTAL the
  values from all
  8 questions,
  If 11 or less
  Score = 0
  If 12 or more
  Score = 2
- Score
- Assign points for
  each of the first
  three responses
Signature
Area Code
Phone Number*

PATIENT HISTORY

PATIENT HISTORY FORM

Other Hospitalizations:

EPWORTH sleepiness scale Questionnaire

COMPLETELY FILL IN ONE CIRCLE FOR EACH QUESTION- ANSWER ALL QUESTIONS