ROS – Subsequent Appointment

Directions: All sections must be completed. Write “ N/A” if not applicable
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…
Are you here for or do you have a history of Asthma?
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.
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…
“Better Sleep, Better Health”
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.
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)



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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