Pulmonary Patient Questionnaire

1. Tell us what respiratory problem we can help you with during your visit:



2. How long have you had this problem?
[0-50]

3. Is this condition worsening, improving, or staying the same?

4. Are there any medical problems associated with this condition?
(Seasonal allergies, Acid Reflux, Obesity, etc. )

5. What previous evaluation and tests have been performed?

6. What were the results of that evaluation?

7. Is there anything that makes the condition worse?

8. Is there anything that makes the condition better?

9. Have you previously received therapy for this condition? If so, what?

10. How far can you walk on level ground?

11. Are you currently on:
liters/minute

12. Do you experience any of the following: