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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
Date
Last Name
*
First Name
*
Middle
Date of Birth
*
Briefly describe the reason for your visit:
Respiratory Symptoms
Do you have any of the following complaints?
Check all that apply:
Shortness of Breath
Yes
No
If Yes, how long?
Are you short of breath resting?
Yes
No
How much can you walk before getting short of breath?
What triggers your shortness of breath?
Do you get Short of breath around
Trees
Pets/Animals
Exercise
Heat
Cold
Humidity
Pollen
Ragweed
Any breathing problems as a:
Child
Teenager
Adult
Do you or have you ever taken any medications for breathing problems? If yes, please list:
Do you have a home nebulizer?
Yes
No
Are you on Home Oxygen?
Yes
No
If you use oxygen, do you use:
Only at night
At night and when I need it during the day
All the time
How long have you used oxygen?
How many pillows do you use under your head when sleeping?
Do you wake up at night short of breath?
Yes
No
or Choking?
Yes
No
Do you have swelling in your feet or ankles?
Yes
No
Do you have a cough?
Yes
No
If yes, how long?
Is it productive?
Yes
No
Color?
Have you ever coughed up blood or streaks of blood?
Yes
No
When?
Have you ever had:
Wheezing
Chest Pains
Heartburn
Choking on food
Runny Nose
Post Nasal Drip
Frequent throat clearing
Nosebleeds
Weight loss
Weight Gain
Skin Rash
Sleep History:
(Check all that apply)
Sleep Apnea
Restless Leg Syndrome
Snoring
Daytime Sleepiness
Daytime Fatigue/Tiredness
Past Medical History:
(Check All that apply)
Have you ever been diagnosed with:
Asthma
Emphysema
COPD
Chronic Bronchitis
Bronchiectasis
Cystic Fibrosis
Blood Clots in legs
Pneumonia
Tuberculosis
Positive TB test
High Blood Pressure
Diabetes
Stomach Ulcer
Heart Attack
Congestive Heart Failure
Lung Cancer
Yes
No
If yes, Did you receive:
Chemo
Radiation
Surgery
Other
Other
When was your diagnosis? Treatment?
Past Surgical History:
(Check all that Apply)
Chest or Lung Surgery
Tonsils Removed
Sinus Surgery
Uterus and/or ovaries removed
Appendectomy
Gall Bladder Removed
Other Surgeries (What and When)
Other Surgeries (What and When)
Family History:
(Blood Relatives, Check all that apply)
Mother
Living
Deceased
Problem
Father
Living
Deceased
Problem
Brothers and/or Sisters Problems:
Children Problems:
Vaccination History:
(Check all that apply)
FLU Shot
Yes
No
When
When
Pneumonia Shot
Yes
No
When
When
Occupational History:
(Check all that apply)
What type of job have you done most of your life?
Have you had exposure to any of the following:
Asbestos (car brakes,pipe fitter, roofing, tiling, boiler work, ship yard work)
Sand/Silica Dust, Cement (construction work)
Smoke inhalation (firefighter)
heavy metal grinding/tool and dye making
Farm work
Mustard Gas, nerve gas, agent orange, lewisite, military experiments
Desert Storm
Veterinarian work
Social History:
(Check all that apply)
Have you ever smoked cigarettes, cigar, or pipe?
Yes
No
Do you currently smoke?
Yes
No
Average Number of packs per day
Number of years you smoked
If you quit, When did you quit?
Number of cups per day of caffeinated beverages
Do you currently smoke marijuana or take other mood altering illicit drugs?
Yes
No
If yes, What and how often?
Have you ever Drank Alcohol?
Yes
No
Do you currently drink alcohol?
Yes
No
How Much?
Environmental History:
(Check all that apply)
Do you have any of the following:
Pets
Dogs
Cats
Birds
Home Air Conditioning
Home Air Cleaner/Hepa Filter
Dusty Environment at home
Other
Other
Travel History:
(Check all that apply)
Travel to Southwest or Midwest
Travel to Far East Countries
Travel to South America/Haiti
When
When
Allergies:
(PLEASE LIST ALL ALLERGIES)
Food Allergy
Allergic to:
Eggs
Peanuts
Medication Allergy
Environmental Allergy
Seen an allergy specialist?
Yes
No
Had Allergy Testing?
Yes
No
When
When
Allergy Shots
Yes
No
When
When
Current Medications
Medication
Dosage
Frequency
Route
1.
Medication
Dosage
Frequency
Route
2.
Medication
Dosage
Frequency
Route
3.
Medication
Dosage
Frequency
Route
4.
Medication
Dosage
Frequency
Route
5.
Medication
Dosage
Frequency
Route
6.
Medication
Dosage
Frequency
Route
7.
Medication
Dosage
Frequency
Route
8.
Medication
Dosage
Frequency
Route
9.
Medication
Dosage
Frequency
Route
10.
Medication
Dosage
Frequency
Route
11.
Medication
Dosage
Frequency
Route
12.
Medication
Dosage
Frequency
Route
13.
Medication
Dosage
Frequency
Route
14.
Medication
Dosage
Frequency
Route
15.
Medication
Dosage
Frequency
Route
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)?
Yes
No
TIRED? Do you often feel tired, fatigued, or sleepy during the daytime (such as falling asleep during driving)?
Yes
No
OBSERVED? Has anyone observed you stop breathing or choking/gasping during your sleep?
Yes
No
PRESSURE? Do you have or are you being treated for high blood pressure?
Yes
No
BMI? Body Mass Index more than 35?
Yes
No
Not Sure
AGE: Older than 50 yrs?
Yes
No
NECK SIZE: For male, shirt collar 17inches or larger? For Female, shirt collar 16inches or larger?
Yes
No
GENDER:
Male
Female
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
What is your primary problem with sleep?
How Long have you had this sleep problem? Months? Years?
SLEEP SCHEDULE and SLEEP HYGIENE:
What time do you usually go to bed?
Weekend/Holiday
Weekday/Workday
What time do you usually get up?
Weekend/Holiday
Weekday/Workday
How many hours do you usually sleep?
Weekend/Holiday
Weekday/Workday
Do you take daytime naps?
Yes
No
Are you usually refreshed by a night's sleep?
Yes
No
Do you keep a fairly regular sleep/wake schedule?
Yes
No
Do you do any of the following in bed? (Check all that apply)
Read
Watch TV
Write
Eat
Worry
Do you currently do shift work?
Yes
No
Have you done shift work in the past?
Yes
No
Do you have trouble sleeping when you are doing shift work?
Yes
No
Not Applicable
If you could set your own schedule, what time would you go to bed?
If you could set your own schedule, what time would you get up?
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?
Yes
No
What is the average number of minutes it takes to fall asleep at night?
Do you often have awakenings during the night?
Yes
No
What is the average number of awakenings per night?
Do you have long periods where you awaken and cannot get back to sleep?
Yes
No
Are you bothered by waking up too early and not being able to get back to sleep?
Yes
No
How many nights a week do you feel you have a problem sleeping?
Is your sleep disrupted by your bed partner?
Yes
No
If Yes, for Snoring
If yes, for moving
If yes, for other reason (please list reason)
If yes, for other reason (please list reason)
PARASOMNIAS:
Did you have a sleep problem as a child?
Yes
No
If yes, please describe
If yes, please describe
Do you currently have night terrors?
Yes
No
If yes, how frequently?
If yes, how frequently?
Do you clench or grind your teeth at night
Yes
No
Have you been told you act out dreams?
Yes
No
Did you frequently wet the bed as a child?
Yes
No
Have you recently walked in your sleep?
Yes
No
Have you ever been told you walk in your sleep?
Yes
No
MOVEMENT:
Answer the following questions based on the last six months
Has your partner ever complained of your legs kicking during the night?
Yes
No
Do you have restless sense of discomfort (crawling sensation) in your legs during the waking hours?
Yes
No
Do you exercise regularly?
Yes
No
EXCESSIVE SLEEPINESS:
Do you feel excessively sleepy in the daytime?
Yes
No
If Yes, How long? Months? Years?
Have you ever had an accident or near miss accident because of falling asleep driving?
Yes
No
If yes, Please describe
Have you ever felt sudden muscle weakness when you laughed, got angry, or were surprised?
Yes
No
Have you been unable to move your body just as you were falling asleep or waking up?
Yes
No
Do you sometimes have difficulty distinguishing your dreams from reality?
Yes
No
If yes, Please describe:
How often do you wake with morning headaches?
Never
Monthly
Weekly
Daily
How often do you wake with dry mouth or sore throat?
Never
Monthly
Weekly
Daily
Have you been told that you stop breathing during sleep?
Some Nights
Every Night
Never
Have awoken with a snort, choking sensation, or shortness of breath?
Some Nights
Every Night
Never
How often do you snore?
Never
Occasionally
Nightly
If yes, How loud is your snoring?
Not Very
Somewhat
Very
Don't Know
Which positions do you prefer to sleep?
Back
Right Side
Left Side
Stomach
Other
Other
Does your sleep position affect your snoring?
Yes
No
Don't Know
N/A
Do you have difficulty breathing through your nose?
Yes
No
If Yes, Please Describe
If Yes, Please Describe
Have you ever had surgery on your upper airway?
Yes
No
If yes, please describe
If yes, please describe
Do you have gastric reflux, heartburn, or a hiatal hernia?
Yes
No
Do you use oxygen or any type of medical equipment when you sleep?
Yes
No
If Yes, Please Describe
If Yes, Please Describe
Have you gained weight?
Yes
No
Have you attempted to diet?
Yes
No
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
0
1
2
3
Watching TV
0
1
2
3
Sitting inactive in a public place
0
1
2
3
As a passenger in a car for an hour
0
1
2
3
Lying down in the afternoon
0
1
2
3
Sitting and talking with someone
0
1
2
3
Sitting quietly after a lunch without alcohol
0
1
2
3
In a car, while stopped for a few minutes in traffic
0
1
2
3
Total
Additional Comments regarding your sleep:
PSYCHOLOGICAL HISTORY:
Do you feel depressed?
Yes
No
Now?
Yes
No
Have you ever seen a psychiatrist or any other type of counselor?
Yes
No
Currently?
Yes
No
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