Health Form - Illinois Lung and Interventional Pulmonary Associates

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Opening Hours

Mon - Fri: 8:30 AM - 4:30 PM

Health Form

Patient’s Name:

DOB:

Preferred Pharmacy:

Pharmacy Phone #:

Past/Present OCCUPATION(S):

Marital Status:

Pets? Type/Number:

Highest Level of Education:

Tobacco Use History:

Number of cigarettes/packs per day:

Cigars: Y N

Electronic cigarettes: Y N

What year/age when you started smoking:

What year did you quit smoking:

Smokeless tobacco/chewing tobacco?:

What year did you quit other tobacco?:

Alcohol History:

Number of drinks per day:

Caffeine History: (coffee, tea, soda, etc.) #Cups per day:

Exercise?:

With whom do you live:

List Current Medications:

NAME	DOSE	FREQUENCY

Allergies to MEDICATIONS:

NAME	Reaction	NAME	Reaction

List ALL Surgical Procedures:

NAME	Reaction	NAME	Reaction

Disease/Condition

	SELF	Father	Mother	Sibling		SELF	Father	Mother	Sibling
Abn Heart Rhythm					Heart Attack (MI)
AIDS					Heart Valve Disorder
Anemia					Hepatitis
					High Blood Pressure
Anxiety					High Cholesterol
					HIV
Asthma					Kidney Disorder
Autoimmune Disorder					Kidney Stones
Bleeding Disorder					Liver Problem
BPH					Neuromuscular Disorder
Cancer (type:)					Osteoarthritis
					Osteoporosis
Cardiomyopathy					Pneumonia
Clotting Disorder					Psoriasis
Colitis					Rheumatoid Arthritis
COPD					Seizures
Coronary Artery/ Disease					Sickle Cell Anemia
Depression					Sleep Apnea
Diabetes Mellitus					Stroke
Eczema					Thyroid Disorder
Emphysema					TIA
Endocrine Problem					Tuberculosis
Fibromyalgia					Other:
Gall Bladder Disease
GERD/Reflux

Tests and Immunizations:

Item (most recent)	Year
Chest X-ray
EKG
Cardiac Stress Test
Allergy Skin Test
Flu vaccine
Shingles vaccine

Item (most recent)	Year
Pneumonia vaccine
Prevnar 13
Pulmonary Function Test
Sleep Study
Sinus X-ray/CT
TB (PPD) test

Current Physicians:

Name	Phone	Specialty

Signature:

Date: