Health questionnaire Intake October 2023

Health Questionnaire + Registration Form

Part 1
WELCOME to the office of
Dr. Bruce Millman

If you have any questions,
please call us at
1-248-965-4165
First name*
Last name*
Birth Date*

MonthDayYear
Email address*
example@example.com
Only used for office administrative, appt reminders, practice updates, your financial account update. We do not sell any patient information
PCP/NP/PA First and Last name *
Enter NA if you don't have one
PCP phone number*
PCP FAX number--- we need this to send our reports to*
How did you hear about us?*
Ask our manager for details--if you refer a pleasant patient , we offer a superb $50 Amazon gift card to you.
I.e. Which doctor , PA, etc?

Consent
Please review our office policy (including No show, cancellation policies and fees)

Office policy update Oct 1 2020 ---(Right click on this to open in a new window)
I have read the above office policy and also understand the fees apply to all patients (new, inpatient, followups). *

Clear

Tell us your FAMILY pulmonary history
Sleep apnea, Asthma, COPD, Sarcoidosis, Blood clots, Lung cancer,
or other lung disease?
Father*
If none, please enter NO
Mother*
If none, please enter NO
Sibling*
If none, please enter NO

MEDICATIONS and ALLERGIES
Medication list upload (please make sure legible with doses)--PDF, JPG, JPEG, PNG only

Upload your medication list
Cancelof
List all of your current medications (include all inhalers and/ or nebulizer medications) *
If you uploaded instead, type "uploaded"
List all ALLERGIES to MEDICATIONS , LATEX, IODINE DYE, TAPES, etc.*
If you don't have any, type "NKDA" (no known drug allergies)

Any other pertinent info that you want to upload?

Cancelof
IMPORTANT: To help optimize your care quickly

At your first appointment, please bring---

1. CD-ROM for any Chest CT scans or chest X-rays from outside the Beaumont system. This way Dr. Millman can look at the images directly. This is the best way for the doctor to really understand your condition.

2. PAPER REPORTS of any ...
- Chest CT scans
- Chest x-rays
- ECHOcardiogram (from your cardiologist office)
- Sleep study reports from your current medical equipment company [call them to fax to our office directly]
3. A list of your inhalers or nebulizer treatment solutions
I will try to get records as above*

Yes, I am a stellar patient and will help out by calling my cpap equipment company or other medical team membersYes, I am a dedicated patient. I will call my doctor’s office and will have them fax records to Dr. Millman’s officeNo, I don’t want to take the time to do this, but understand that this will delay diagnosis and treatmentI don’t have any records that are pertinent to my medical care at all (recent non Beaumont records).
Any other comments or suggestions?

Click the below "REVIEW" button to review your answers so far. We suggest to print and bring to your appointment as well (in case there are any upload issues). After reviewing your answers, then you will be taken to our PART 2 sleep questionnaire to complete as well. Thank you!
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Health Questionnaire + Registration Form