Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pediatric Pulmonology Medical History Form
Child's Name
Date of Birth
____ / ____ / ________
Primary Respiratory Symptoms
Birth History (Gestational Age, NICU)
Chronic Cough Duration and Pattern
Wheezing Frequency and Triggers
Asthma Exacerbation History
Current Respiratory Medications
| Medication | Dose | How often |
|---|---|---|
Environmental Exposures
Pediatric Pulmonology Medical History Form template from formisoft.com. formisoft.com/intake-templates/pediatric-pulmonology-medical-history