• Lake Mary | Oviedo

    • (407) 321-8230(407) 321-0388

  • Orange City

    • (386) 917-0333(386) 917-0335
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      • ROS – Subsequent Appointment

      Directions: All sections must be completed. Write “ N/A” if not applicable

      PATIENT INFORMATION

      SYMPTOMS: Are you having any of these symptoms (check all that apply):

      FeverNight SweatsChillsRashesShortness of BreathWheezingCough
      Sputum: Color
      Blood in SputumHeadacheSinus CongestionNasal DischargeDischage drips down throat causing coughExcessive ThirstSwollen Glands (neck)Sore ThroatDifficulty SwallowingHoarsenessChest Pain / DiscomfortPleuritic Chest PainChest TraumaFeelings of WeaknessFaintingParalysisSeizure(s)AnxietyDepression

      Weight ChangeAbdominal PainNauseaVomitingDiarrhea
      HeartburnCauses Awakeningwith Regurgitation
      Calf TendernessLeg SwellingLimb SwellingLegs feel RestlessSnoringSleepinessFatigueSleep too muchInsomniaSleep DisturbanceMuscle AchesJoint Pain / ArthritisHearing LossFast Heart RatePalpitation
      Exposure to…
      AsbestosFumesSandblasting

       

      Are you here for or do you have a history of Asthma?
      YesNo

      Are you here for Sleep Apnea / Sleep Problems? YesNo

      Current Smoker?   . If No Longer a smoker, when did you quit? Date/Years

      Any Changes in your Family, Social, Medical, or Surgical History since you last appointment?   If Yes, please list changes
      on back of this page.

       

      VACCINATION INFORMATION

      Have you received your FLU vaccine this year?   

      When was your last Pneumonia Shot? Date/Year   Prevnar 13 Shot? Date/Year

       

      Asthma Assesment Tool

      (Only Complete if you were previously diagnosed with Asthma)

      1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much
      done as usual at work, school, or at home?

      1 (All of the time)2 (Most of the time)3 (Some of the time)4 (A little of the time)5 (None of the time)

      2. During the past 4 weeks, how often have you had shortness of breath?

      1 (More than once a day)2 (Once a day)3 (3-6 times a week)4 (Once or twice a week)5 (Not at all)

      3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortnes of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?

      1 (4 or more nights a week)2 (2-3 nights a week)3 (Once or twice a week)(4 Once a week)5 (Not at all)

      4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?

      1 (3 or more times per day)2 (1 or 2 times per day)3 (2 or 3 times per week)4 (Once a week or less)5 (Not at all)

      5. How would you rate your asthma control during the past 4 weeks?

      1 (Not controlled at all)2 (Poorly controlled)3 (Somewhat controlled)4 (Well controlled)5 (Completely controlled)

       

       

      Daytime asthma symptoms occur…

      Nighttime asthma symptoms…

       

       

      ADVANCED SLEEP DISORDER CENTER

      at

      PULMONARY PRACTICE ASSOCIATES

      “Better Sleep, Better Health”

      CPAP CLINIC FOLLOW-UP REPORT

      (inches)

       

      Rate each description according to your normal way life in recent times. Even if you have not been in some of these
      situations recently, try to determine how sleepy you would have been.
      Use the following scale to choose the best number for each situation:

       

      0 = would never doze.

      1 = would have a SLIGHTLY CHANCE of dozing.

      2 = would have a MODERATE CHANCE of dozing.

      3 = would have a HIGH CHANCE of dozing.

       

      SITUATION:

      Likelihood of falling asleep:

      CHANCE OF DOZING

      1. During the day, after lunch, without alcohol

      2. Sitting and reading

      3. Watching TV

      4. Sitting inactive in a public place (e.g. theater, or in a meeting)

      5. Sitting as passenger in a car for an hour without a break

      6. Lying down to rest in the afternoon

      7. Sitting and talking to someone

      8. In a car while stopped in traffic

       

      Total Score

      Answer the question below ONLY IF you have had CPAP or BiPAP ordered:

      Do you feel your treatment has improved your quality of life and health?

      If yes, how? (check all that apply)


       

       

       

      ABOUT US

      When it comes to breathing disorders, our physicians and staff at Pulmonary Practice Associates understand how important it is for you to choose a qualified physician who will provide the best care possible to get you back to living a healthy and comfortable life.


      1075 Town Center Dr, Orange City, FL 32763
      Phone Number: (386) 917-0333
      Fax Number: (386) 917-0335

      749 Stirling Center Place, Lake Mary, FL 32746
      Phone Number: (407) 321-8230
      Fax Number: (407) 321-0388

      8400 Red Bug Lake Road, Suite 2010, Oviedo, FL, 32765
      Phone Number: (407) 321-8230
      Fax Number: (407) 321-0388

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