Follow Up Patient Form

Follow Up Patients
Appointment Location *

In Person Telemedicine
Patient's Full Name *

First Name Last Name
What is your Gender?

Male Female
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 *

Oren Maclean Palumbo Balekian Ober Maciag
Appointment Date *

Month Day Year
Date
Appointment Time *

: Hour Minutes AM/PM Option
What is the reason for your visit? *
Are you Allergic to any medications?

No
Current Medications
Any pets in the house?
Do you use or do you have history of using tobacco?
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

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

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

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

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

1 is Not controlled at all, 5 is Completely controlled

Should be Empty:

Follow Up Patients

Asthma Patients - please complete