Pulmonology Intake Form

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.