Pulmonary Associates of St Augustine
Kishwar Husain, M.D.   Javier Aduen, M.D.   Faisal Usman, M.D.
300 Health Park Blvd, Suite 4000  St Augustine, FL 32086
904-824-8666   904-824-8933 Fax

Clinical Intake Form

Respiratory Symptoms

Do you have any of the following complaints? Check all that apply:
Shortness of Breath
Are you short of breath resting?
Do you get Short of breath around
Any breathing problems as a:
Do you have a home nebulizer?
Are you on Home Oxygen?
If you use oxygen, do you use:
Do you wake up at night short of breath?
or Choking?
Do you have swelling in your feet or ankles?
Do you have a cough?
Is it productive?
Have you ever coughed up blood or streaks of blood?
Have you ever had:
Sleep History: (Check all that apply)
Past Medical History: (Check All that apply)
Have you ever been diagnosed with:
Lung Cancer
If yes, Did you receive:
 
Past Surgical History: (Check all that Apply)
 
Family History: (Blood Relatives, Check all that apply)
Mother
Father
Vaccination History: (Check all that apply)
FLU Shot
 
Pneumonia Shot
 
Occupational History: (Check all that apply)
Have you had exposure to any of the following:
Social History: (Check all that apply)
Have you ever smoked cigarettes, cigar, or pipe?
Do you currently smoke?
Do you currently smoke marijuana or take other mood altering illicit drugs?
Have you ever Drank Alcohol?
Do you currently drink alcohol?
Environmental History: (Check all that apply)
Do you have any of the following:
 
Travel History: (Check all that apply)
 
Allergies: (PLEASE LIST ALL ALLERGIES)
Allergic to:
Seen an allergy specialist?
Had Allergy Testing?
 
Allergy Shots
 
Current Medications
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STOP BANG:
SNORING? Do you snore loudly (loud enough to be heard through closed doors, or your bed partner elbows you for snoring at night)?
TIRED? Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving)?
OBSERVED? Has anyone observed you stop breathing or choking/gasping during your sleep?
PRESSURE? Do you have or are you being treated for high blood pressure?
BMI? Body Mass Index more than 35?
AGE: Older than 50 yrs?
NECK SIZE: For male, shirt collar 17inches or larger? For Female, shirt collar 16inches or larger?
GENDER:
If you are seeing the doctor for an issue related to your sleep,
please fill out the sleep questionaire below.
If your issue is not sleep related, please scroll to the end and click on the submit button.

Sleep Confidential Questionnaire

SLEEP SCHEDULE and SLEEP HYGIENE:
 
What time do you usually go to bed?
What time do you usually get up?
How many hours do you usually sleep?
Do you take daytime naps?
Are you usually refreshed by a night's sleep?
Do you keep a fairly regular sleep/wake schedule?
Do you do any of the following in bed? (Check all that apply)
Do you currently do shift work?
Have you done shift work in the past?
Do you have trouble sleeping when you are doing shift work?
INSOMNIA:
Based on your experience in the last six months answer the following questions, with "night" meaning your major sleeping time.
Do you often have trouble falling asleep?
Do you often have awakenings during the night?
Do you have long periods where you awaken and cannot get back to sleep?
Are you bothered by waking up too early and not being able to get back to sleep?
Is your sleep disrupted by your bed partner?
 
PARASOMNIAS:
Did you have a sleep problem as a child?
 
Do you currently have night terrors?
 
Do you clench or grind your teeth at night
Have you been told you act out dreams?
Did you frequently wet the bed as a child?
Have you recently walked in your sleep?
Have you ever been told you walk in your sleep?
MOVEMENT:
Answer the following questions based on the last six months
Has your partner ever complained of your legs kicking during the night?
Do you have restless sense of discomfort (crawling sensation) in your legs during the waking hours?
Do you exercise regularly?
EXCESSIVE SLEEPINESS:
 
Do you feel excessively sleepy in the daytime?
Have you ever had an accident or near miss accident because of falling asleep driving?
Have you ever felt sudden muscle weakness when you laughed, got angry, or were surprised?
Have you been unable to move your body just as you were falling asleep or waking up?
Do you sometimes have difficulty distinguishing your dreams from reality?
How often do you wake with morning headaches?
How often do you wake with dry mouth or sore throat?
Have you been told that you stop breathing during sleep?
Have awoken with a snort, choking sensation, or shortness of breath?
How often do you snore?
If yes, How loud is your snoring?
Which positions do you prefer to sleep?
 
Does your sleep position affect your snoring?
Do you have difficulty breathing through your nose?
 
Have you ever had surgery on your upper airway?
 
Do you have gastric reflux, heartburn, or a hiatal hernia?
Do you use oxygen or any type of medical equipment when you sleep?
 
Have you gained weight?
Have you attempted to diet?
EPWORTH SLEEPINESS SCALE:
 
How likely are you to doze off or fall asleep in the following situations, in contrast to 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 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
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking with someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
PSYCHOLOGICAL HISTORY:
Do you feel depressed?
Now?
Have you ever seen a psychiatrist or any other type of counselor?
Currently?