Please complete. If you have an additional person coming in to assist you with the visit, please have them complete this questionnaire. Make sure to add temperature with all details included, please. If completing for an appointment, complete form 10 days or less before coming to office. If unable to complete the form, please call office.
Your Symptoms
SYSTEMIC OR DANGEROUS SYMPTOMS
after cough
SYMPTOM COURSE
Blood in sputum
SOCIAL HISTORY
Medical History
TREATMENTS TRIED
MEDICAL HISTORY
FEMALE HISTORY
ANYTHING ELSE