a	Mark Sigler, M.D.
Pulmonology

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Amarillo...,,	' Cllnir.P.A.

PATIENT QUESTIONNAIRE- PLEASE PRINT

Full name: 		 Date:	Age:
CHIEF COMPLAINTS(List the problems about which you came to see the doctor)

1)

2)

3)
Referring Physician	 		Other Physician 	 PAST MEDICAL HISTORY
MedicalIllness:  Please check any of the following medicalIllnesses that you now have or have ever had,or
list anv others that are not listed below.
C Cataracts	-. Skin cancer	: PancreaiJIIs
]Glaucoma	:. Psoriasis	: Diverticulosis
:.J Chronic Bronchitis	·,Diabetes	Liver disease
]Emphysema	Malaria	: Hepatitis
]Pneumonia	_  Sexually transmitted disease	:Stomach ulcers
J Any type of heart problems	::Tuberculosis	·JHiatalhernia
CJ Heart attack	J Thyroid disease	: Kidney problems
w Heart catheterlzallon	_ Treatment for depression	-Kidney stones
J Rheumauc Fever	. Tension/Anxiety/Nerves	Miscarriage
. High blood pressure	. Os!eo Arthritis	Blood Clots
Stroke	,Rheumatoid Arthritis	i Stress fractures

'

High cholesterol	. 	J Gallbladder disease	Other

. • Anv tvoe or cancer

•'	Colon polyps	-
I	OPE.RATIONS OR SURGERIES

Please list all oasloperatlons,lncludll!g_ calaracttsurgtry, what type of surgery_lt was and when It was done
i	Type 	Date

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Have you ever had a colonoscopy?  	YEB.....__	NO Describe any serious accidents or disabling Injuries:
Type 	Date

Revised 08111/06	Pg1  	_

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··-	Past Hospitalizations		
Listyour past hostalizations, year hospitalized and reason for hospitalization		
Hospitalization	Year Hospitalized	Reason		

				

PLEAE LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING. t3E SURE TO
INGLUDE ANY HORMONES, VITAMIN E,NIACIN,FISH OIL, CO-Q 10 & ASPIRIN		
Name	Dose (le # of tablets)	How often		
	I			

				
				
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Do you take any of the following:		

Aspirin	e Yes  o No 	Birth control pills  c Yes	o No 	Laxatives	o Yes  r;: No
Hormones	o Yes	1:1  No	Vitamins	Yes	o No 	Blood thinners c Yes  o No		
ALLERGIES		

Please list any medications or products you have taken which cause a true allergic reaction (hives,Itching, rash, or difficulty breathing): 			

RPvi<:M 011111lOA

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	IMMUNIZATIONS	
	
Last flu shot 		Pneumonia shot   o Yes c No	When? 		
	SOCIAL HISTORY	
	Current employment  status:	o Disabled 	o Part time 	o Full time 	o Retired 	o Self-employed 	o Other	
	What type of occupation do you (or did) you have?	
	Where do you live?	
	Current marital status? 	= Single 	c Married	a Separated 	c:; Divorced 	c Widowed 	o Other	
	
How many children do you have? # 		# 	Sons 	# 	Daughters	
	HA ITS	
	
Have you ever smoked cigarettes regularly?	o Yes 	o No 	If yes, how many packs per day? (avg) How many years? 	Are you still smoking? o Yes 	 o No 	If no, when did you stop?	
	
Do you use snuff or chewing tobacco?    e Yes 	o No 	Do you drink alcohol? 	a Yes 	o No	
	How many beers daily? 	How many years? How many mixed drinks or glasses of wine daily? 	How many years?	
	Do you have any drug, nicotine or alcoholhabits which concern you? 	a Yes 	o No	
	Do you regularly use sleeping pills, tranquilizers, or pain killers? 	o Yes 	o No

If yes, which ones?	
	
Do you currently use marijuana, cocaine or other "recreational" drugs? 	o Yes 	o No	
	FAMILY HISTORY
Please list any dise  ses whjch tend to "run Inyour family" especially high blood pressure, diabetes,heart disease, cancer, gout,
asthma,stomach ulcers, arthritis,aliergles, epilepsy, tuberculosis, cystic fibrosis,muscle disease, stroke or thyroid disease.	
	Father's Hlstol'Y_	
	Is your Father? 	o Alive - Age 	o Deceased -Age

What types of health problems if any did he have?	
	Mother's History	
	Is your Mother? 	o Alive - Age 	c Deceased - Age

What types of health problems if any did she have?	
	Do y_ou have any brothers?	
	How many? 	o Alive -Ages	o Deceased - Ages

What types of health problems do/did they have?	
	Do you have any sisters?	
	
How many? 	o Alive - Ages 	a Deceased- Ages

What types of health problems do/did they have?	
	If you served In the military:	
	Were you ill while in the military? 	o Yes 	o No 	What was the nature of the illness?
Did you serve overseas? 	o Yes 	o No	 If yes, where & when?	
	Have you traveled outside of the Amarillo area in the past year? 	o Yes 	o No

If so, please list the places you have been:	
	
Please list all pets or any other animals which you may have been in contact with in the past year.	

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..	REVIEW OF SYSTEMS
Please check any of the following symptoms or problems you are currently experiencing. If the problem has been resolved, leave It blank. If you are unsure, place a question mark(?)  by the medicalIssue.
General	Skin 	Head/Ear/Eyes/Nose/Throat o Weight loss 	o Recent change in hair distribution	o Diplopia (double vision)
o Weight gain 	o Changes in skin color 	o Glaucoma

o Fatigue 		o Itching 	o Hearing loss o Fever 		o Rash 	o Nose bleeds o Night sweats 		o Hair loss 	o Sore throat Do you eat a special diet?	oYes oNo 	o Other 	o Other
Do you exercise regularly?  aYes  oNo

Neck 	Respiratory 	Breast/GYN

o Neck mass 	o Cough 	o Breast discharge
o Neck pain 	o History of Tuberculosis	o Breast swelling 	o Breast mass o Neck stiffness 	o Shortness of breath 	o Breast tenderness
o Swollen glands 	a Wheezing	o Menses:Last one?
o Other 	o Other 	o # Miscarriage

o Other 	 Cardiovascular	Gastrointestinal 	Genitourinary
o Chest pain 	o Abdominal pain 	o Blood in urine

o Edema (swelling) 	o Nausea 	o Dysuria (pain with urination)

o FasVIrregular heartbeat 	o Vomiting 	o Frequency of urination

'r.    o Orthopnea (trouble breathing while 	o Constipation/Diarrhea 	o Discharge
lying down) 	o Reflux 	o Nocturia (excessive urination at night)

o Other 	o Other 	o History of malignancy (cancer)

o Other 	 Musculoskeletal	Neurological 	Psychological
o Arthritis 	o Headaches 	o Anxiety

o Back pain 	o Seizures 	a Depression o Joint pain 	o Strokes 	o Insomnia
o Other 		o Other	o Other 	

Endocrine 	Hematological 	Other o Cold intolerance 	o Anemia
o Heat intolerance 		 o Easy bleeding o Thyroid problems 		o Easy bruising o Other 		o Other

Patient Signature	Physician Signature

Date

Revised OB/11108

Date
We appreciate your cooperation in completing this form for your physician.

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