Skip to content
Pulmonary & Sleep Disorders of New York, P.C.
Intake Form
Menu
Intake Form
2625 East 14th Street, Suite 201
Brooklyn, NY 11235
Tel. 718-891-7800
Fax. 718-332-7246
Today's Date:
Patient’s Name
Address
Date of Birth
Patient’s Phone#
Person completing the form
Relationship to patient
Contact Phone#
Preferred Email:
Insurance Information
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:
WOMENS REPRODUCTIVE HISTORY:
Age of first period:
# Pregnancies:
# Miscarriages:
# Abortions:
Have you reached menopause? At what age?
Do you have regular periods?
Yes
No
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
Send
