Pulmonary & Sleep Disorders of New York, P.C. – Pulmonary & Sleep Disorders of New York, P.C.

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Pulmonary & Sleep Disorders of New York, P.C.

Intake Form

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Intake Form

2625 East 14th Street, Suite 201

Brooklyn, NY 11235

Tel. 718-891-7800

Fax. 718-332-7246

E-mail: psdny1@gmail.com

Today's Date:

Patient’s First Name

Patient’s Last Name

Address

Date of Birth

Patient’s Phone#

Preferred Email:

Person completing the form

Contact Phone#

Relationship to patient

Name of Insurance

Insured ID #

PREFERRED PHARMACY NAME

PHARMACY ADDRESS

PHARMACY PHONE NUMBER

MEDICATIONS LIST
Please include PLAVIX, FISH OIL, COUMADIN, ASPIRIN OR any blood thinning medication.
PRESCRIPTION MEDICATION Name

Dose (ex. 2mg, 1tsp)

How Often? (ex. 3x/day)

Medication Name

Dose (ex. 2mg, 1tsp)

How Often? (ex. 3x/day)

Medication Name

Dose (ex. 2mg, 1tsp)

How Often? (ex. 3x/day)

Other Medications

ALLERGIES

Notes

PATIENT INITIAL VISIT SELF-ASSESSMENT FORM
Marital Status

Single Married Divorced Widowed Separated Domestic Partner

Referral information:
How were you referred to us?

WEBSITE HEALTH PLAN DIRECTORY FAMILY/FRIEND PHYSICIAN INTERNET PHYSICIAN REFERRAL SERVICE MAGAZINE OTHER

Please specify

Referring Physician:

Phone

Fax:

Address:

Primary Care Physician

Phone

Fax:

Address:

Other Doctors You Want Your Records To Be Sent To:

Health Information:
Reason for today’s visit:

Other diseases and / or problem:

PLEASE INDICATE IF YOU HAVE ANY OF THE FOLLOWING:
COVID-19

Yes No

If Yes, When?

Angina

Yes No

If Yes, When?

Angioplasty

Yes No

If Yes, When?

Arrhythmia

Yes No

If Yes, When?

Heart Attack

Yes No

If Yes, When?

Congestive Heart Failure

Yes No

If Yes, When?

Coronary Artery Disease

Yes No

If Yes, When?

Mitral Valve Prolapse

Yes No

If Yes, When?

High Blood Pressure

Yes No

If Yes, When?

High Cholesterol

Yes No

If Yes, When?

Atrial Fibrillation

Yes No

If Yes, When?

Stroke

Yes No

If Yes, When?

Seizure

Yes No

If Yes, When?

Vascular Disease

Yes No

If Yes, When?

Deep Vein Thrombosis

Yes No

If Yes, When?

Blood Clot in Lungs

Yes No

If Yes, When?

Chron’s Disease

Yes No

If Yes, When?

Asthma

Yes No

If Yes, When?

Emphysema/COPD

Yes No

If Yes, When?

Tuberculosis

Yes No

If Yes, When?

Pneumonia

Yes No

If Yes, When?

Acid Reflux

Yes No

If Yes, When?

Barrett’s Esophagus

Yes No

If Yes, When?

Ulcers

Yes No

If Yes, When?

Diabetes

Yes No

If Yes, When?

Thyroid Disorder

Yes No

If Yes, When?

Liver Disease

Yes No

If Yes, When?

Hepatitis/Jaundice

Yes No

If Yes, When?

Kidney Dysfunction

Yes No

If Yes, When?

Dialysis

Yes No

If Yes, When?

Cancer/Tumors

Yes No

If Yes, When?

Arthritis/Joint Pain

Yes No

If Yes, When?

Depression/Anxiety

Yes No

If Yes, When?

Glaucoma

Yes No

If Yes, When?

Leg Swelling

Yes No

If Yes, When?

Psoriasis

Yes No

If Yes, When?

Sleep Apnea

Yes No

If Yes, When?

Rheumatic fever

Yes No

If Yes, When?

Others / Comments

HAVE YOU EVER HAD SURGERY?

Yes No

If yes, please list the type of surgery and when you had it done

Have you ever been hospitalized for any reason other than surgery?

SOCIAL HISTORY:
Do you smoke?

Yes No

Cigarettes/Cigars/Pipe?

How many packs a day

How many years?

Did you smoke?

Yes No

Quit?

Yes No

If yes, when did you quit?

Do you drink alcohol?

Yes No

Type of Alcohol:

How many drinks a week?

Do you use recreational drugs?

Yes No

If yes, please specify:

Please Specify

IV Smoke Intranasal

Do you exercise regularly?

Yes No

How often?

What type of exercise?

What is your Height?

What is your Weight?

Last Blood Pressure (if known)

In the past month, have you had any of the following problems?
GENERAL
Recent weight gain; how much

Recent weight loss: how much

Fatigue Weakness Fever Night sweats

MUSCLE/JOINTS/BONES

Numbness Joint pain Muscle weakness Joint swelling

Where?

EARS

Ringing in ears Loss of hearing

EYES

Pain Redness Loss of vision Double or blurred vision Dryness

THROAT

Frequent sore throats Hoarseness Difficulty in swallowing Pain in jaw

HEART AND LUNGS

Chest pain Palpitations Shortness of breath Fainting Swollen legs or feet Cough

NERVOUS SYSTEM

Headaches Dizziness Fainting or loss of consciousness Numbness or tingling Memory loss

STOMACH AND INTESTINES

Nausea Heartburn Stomach pain Vomiting Yellow jaundice Increasing constipation Persistent diarrhea Blood in stools Black stools

SKIN

Redness Rash Nodules/bumps Hair loss Color changes of hands or feet

BLOOD

Anemia Clots

KIDNEY/URINE/BLADDER

Frequent or painful urination Blood in urine

Women Only:

Abnormal Pap smear Irregular periods Bleeding between periods PMS

PSYCHIATRIC

Depression Excessive worries Difficulty falling asleep Difficulty staying asleep Difficulties with sexual arousal Poor appetite Food cravings Frequent crying Sensitivity Thoughts of suicide / attempts Stress Irritability Poor concentration Racing thoughts Hallucinations Poor concentration Racing thoughts Guilty thoughts Paranoia Mood swings Anxiety Risky behavior

OTHER PROBLEMS:

PERSONAL HISTORY
What is your current or past occupation?

Are you currently working?

Yes No

If not, are you

retired disabled sick leave

Immunizations
Did you have your Flu Vaccine?

Yes No

Date

Did you have Pneumonia Vaccine?

Yes No

Date

SIGNATURE

The information is accurate and complete to the best of my knowledge. I will not hold the physician or his staff responsible for any error or omission that I may have made completing this form.

ELECTRONIC SIGNATURE

TODAY'S DATE

Pulmonary & Sleep Disorders of New York, P.C.

2625 East 14th Street, Suite 201

Brooklyn, NY 11235

Tel. 718-891-7800

Fax. 718-332-7246

E-mail: psdny1@gmail.com