Pulmonology Intake Form
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Pulmonology Intake Form
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The Pulmonology Intake Form is tailored for respiratory medicine practices, collecting the detailed pulmonary history that pulmonologists need for thorough evaluation of breathing disorders. This template captures patient demographics alongside a comprehensive respiratory symptom assessment covering dyspnea (onset, severity, triggers, MRC breathlessness scale), chronic cough (duration, character, sputum production), wheezing, hemoptysis, chest tightness, and exercise intolerance. The smoking history section uses pack-year calculations and documents cessation attempts, vaping history, and secondhand smoke exposure.
Designed for general pulmonology, asthma and allergy, COPD management, interstitial lung disease, and pulmonary hypertension practices, this form includes sections for prior pulmonary function testing (spirometry, DLCO, lung volumes, bronchoprovocation), chest imaging review (X-ray, CT, HRCT), sleep study results, bronchoscopy history, and oxygen therapy documentation (flow rate, hours of use, delivery device). The environmental and occupational exposure section captures workplace hazards, asbestos exposure, mold exposure, and dust inhalation history relevant to occupational lung disease.
All fields are HIPAA-compliant and structured to support the pulmonary consultation workflow. The multi-page layout guides patients through respiratory symptom domains, ensuring that critical details about triggers, exposures, and prior diagnostic workup are captured before the visit. This allows the pulmonologist to review patterns, identify gaps in prior testing, and plan appropriate diagnostic evaluation including pulmonary function testing, imaging, or bronchoscopy.
What's included
- Dyspnea severity and breathlessness assessment
- Smoking and vaping history with pack-year calculation
- Environmental and occupational exposure screening
- Prior pulmonary function and imaging history
- Respiratory medication reconciliation including inhalers
- Oxygen therapy documentation and compliance
- Allergy documentation with severity levels
- E-signature capture
- Structured medication list with dosage and frequency tracking
- Insurance information collection with carrier and policy details
Who uses this template
- General pulmonology and respiratory medicine practices
- Asthma and COPD management clinics
- Interstitial lung disease and pulmonary fibrosis centers
- Occupational lung disease evaluation programs
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Pulmonology Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Pulmonology Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Pulmonology Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Pulmonology Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Pulmonology Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Pulmonology Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Pulmonology Intake Form for your practice. Set up in minutes.
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