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English (US)
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Follow Up Patients
Appointment Location
*
In Person
Telemedicine
Patient's Full Name
*
First Name
Last Name
What is your Gender?
Male
Female
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Referring Doctor
Your Doctor
*
Balekian
Oren
Maclean
Palumbo
Maciag
Schaefer
Appointment Date
*
-
Month
-
Day
Year
Date
Appointment Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the reason for your visit?
*
Are you Allergic to any medications?
No
Other
Current Medications
Any pets in the house?
Do you use or do you have history of using tobacco?
Yes - Current
Quit/Former
No/Never
Do you use or have history of using tobacco? Live with smoker? Select all that apply
No/Never
Yes - Currently
Quit/Former
Smoker in house
Do you experience any of the following? Check all that apply:
*
Recurrent Fevers
Fatigue
Weight Gain
Weight Loss
Blurred Vision
Light Flashes
Hearing Difficulty
Nose Bleeds
Hoarseness
Neck Swelling
Fluttering Heart
Chest Pain
Swollen Ankles
Cough
Wheeze
Shortness of Breath
Poor Exercise Tolerance
Heartburn
Stomach Pains
Vomiting
Diarrhea
Pain on Urination
Excessive Sweating
Constant Thirst
Feeling too Warm
Feeling too Cold
Painful/Swollen Joints
Rashes
Itching
Depression
Anxiety
NONE OF THE ABOVE
Asthma Patients - please complete
In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
1
2
3
4
5
All of the time
None of the time
1 is All of the time, 5 is None of the time
During the past 4 weeks, how often have you had shortness of breath?
1
2
3
4
5
More than once a day
Not at all
1 is More than once a day, 5 is Not at all
During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
1
2
3
4
5
4 or more nights a week
Not at all
1 is 4 or more nights a week, 5 is Not at all
During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
1
2
3
4
5
3 or more times per day
Not at all
1 is 3 or more times per day, 5 is Not at all
How would you rate your asthma control during the past 4 weeks?
1
2
3
4
5
Not controlled at all
Completely controlled
1 is Not controlled at all, 5 is Completely controlled
Submit
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