ࡱ> c  bjbj 7x[\x[\enn82d`!j*****  $"%t!!**!kkkR** k kkk*Ծg1WFk 0!0`!k%%kk%Lk!!`!%n> : Name: Date of Birth: Ref. Dr: Why are you here to see a pulmonary (lung) doctor? Name and location of your local pharmacy: Mail away? Are you allergic to any medications? ( Yes ( No If so, reaction: Date of last Flu Vaccine: Date of last Pneumonia Vaccine: Do you have hay fever? ( Yes ( No Do you have a history of Lung Cancer? ( Yes ( No Past surgical/procedure historyPast medical historyPlease check each one that applies to you: Do you now or have you ever had:( Eye Surgery( Lung Surgery( Gallbladder Surgery( Tonsils/Adenoid Removal( Diabetes( Heart murmur( GERD( Appendix Removal( Hip Surgery( High blood pressure( Pneumonia( Colitis( Colon Surgery( Rectal Surgery( High cholesterol( Pulmonary embolism( Anemia( Colonoscopy ( Upper Endoscopy( Hypothyroidism( Asthma( Gout( Thyroid Surgery( Carotid Surgery( Goiter( Emphysema( Hepatitis( Fractured Nose Surgery ( Knee Surgery ( Back Surgery( Heart Surgery ( Prostate Surgery ( Hysterectomy( Cancer (type) ______________( Stroke( Stomach or peptic ulcer( Shoulder Surgery( Other Bone Surgeries( Heart Failure( Epilepsy (seizures)( Liver Problems( Sleep Apnea( Cataracts( Tuberculosis( Electrocardiogram( Pulmonary Function Test( Angina( Kidney disease( Restless Leg Syndrome( Bronchoscopy( Chest X-Ray( Heart attacks( Kidney stones( ArthritisPlease list any other surgical procedures:Please list any other medical problems: PERSONAL HISTORY Marital status: ( Never married ( Married ( Divorced ( Separated ( Widowed ( Partnered/significant other What is your current or past occupation? Are you currently working? ( Yes ( No Hours/week ______ If not, are you ( retired ( disabled ( sick leave Have you ever smoked? ( Yes ( No Packs per day? ______ Do you still smoke? ( Yes ( No Do you consume alcohol? ( Yes ( No Drinks per day? ______ FAMILY HISTORY If living If deceased Age (s) Health Age(s) at death Cause Father Mother Brother Sister Have any close family members had the following? Tuberculosis? Lung Cancer? Emphysema? ( Yes ( No ( Yes ( No ( Yes ( No Have you ever worked with any of the following occupational exposures? (Please Circle) Factory Jobs Sandblasting Mining Jobs Construction Jobs Foundry Jobs Asbestos Exposure Dust Exposure PLEASE CONTINUE ON BACK REVIEW OF SYSTEMSIn the past month, have you had any of the following problems?GeneralHEART AND LUNGSPSYCHIATRIC ( Recent weight gain; how much____( Chest pain( Depression( Recent weight loss: how much____( Palpitations( Unusual Thoughts( Fatigue( Shortness of breath( Nervousness( Weakness( Fainting( Crying( Fever( Swollen legs or feet( Sadness( Night sweats ( Chills ( Trouble sleeping ( Loss of Appetite ( Tremors/Shakes( Cough ( Coughing up blood ( Wheezing ( Tuberculosis( Suicide AttemptsMuscle/Joints/BonesSTOMACH AND INTESTINESOTHER PROBLEMS:( Numbness/Weakness( Nausea( Joint pain( Heartburn( Arthritis( Stomach pain( Joint swelling/redness( Vomiting( Gout( Yellow jaundice( Increasing constipationEARS( Persistent diarrhea( Ringing in ears( Blood in stools( Loss of hearing( Black stoolsEYESSKIN( Cataracts( Redness( Redness/Dryness( Rash( Loss of vision( Nodules/bumps( Double or blurred vision( Hair loss( Glaucoma( Color changes of hands or feetTHROAT/SINUSBLOOD( Frequent sore throats( Anemia( Hoarseness( Clots( Difficulty in swallowing( AllergiesKIDNEY/URINE/BLADDER( Frequent or painful urinationNERVOUS SYSTEM( Blood in urine( Headaches( Dizziness/Loss of balanceENDOCRINE( Fainting/Loss of consciousness( Thyroid Disorders( Numbness or tingling ( Diabetes( Memory loss( Excessive Thirst( Stroke( Excessive Hunger List names of all physicians1.4.2.5.3.6.     3 CITRUS PULMONARY CONSULTANTS AND SLEEP DISORDERS CENTER HISTORY & PHYSICAL 2  '*+^g  1 5 L M S T õõõõõõyhy h65;CJOJQJ^JaJ h}G5;CJOJQJ^JaJhr&h PCJaJ h6h6CJOJQJ^JaJh6>*CJOJQJ^JaJh6CJOJQJ^JaJ jqh6CJOJQJ^JaJh4=+>*CJOJQJ^JaJh6>*CJOJQJ^JaJh6CJOJQJ^JaJ%+g5 akd$$Ifl0VP)  t0)44 lapyt=#$If    ' ( ) 6 : ; < P Q R j k l v w ´Рvh^pCJOJQJ^JaJh6Wh<CJaJ h6Wh<CJOJQJ^JaJ& jqh6Wh<CJOJQJ^JaJh}GCJOJQJ^JaJh<CJOJQJ^JaJh6Wh}GCJaJ h6Wh}GCJOJQJ^JaJ&h6Wh}G5;CJOJQJ^JaJ.     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