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Pulmonary Medicine of Dayton, Inc.

Felipe A. Rubio, MD Hemant M. Shah, MD Mariano M. Iberico, MD Salman S. Razi, MD Median Ali, MD

Name:____________________________ DOB:__________________

Home #_______________________

Work #________________________

Referring physician:

________________________ phone:

__________________________

Family physician:

__________________________ phone:

__________________________

Other physicians: __________________________ phone: __________________________

Why are you seeing the lung doctor? (please describe your symptoms)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_____________________________________________________________________________________ _________________________________________________________________________ Abnormal Chest X-Ray/CatScan____________________________________________________

CURRENT PROBLEMS: Cough______________________________________ Onset __________________________ Clear / Green / Yellow (thick / thin / Sticky) _______________________________________

Coughing up blood _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A m o u n t ( T S P / T B S P / S t r e a k s ) _ _ _ _ _ _ _ _ _ _ _ Shortness of Breath (with or without activity)_______________________________________ Chest heaviness / Pressure / Tightness_____________________________________________ Do you Snore (heavy / Light) ______________________ Wheezing (all the time / with activity)________________ Weight Loss (how much / over how long)_____________ Headaches _______________________ Nasal Drainage (clear/green/yellow)_________________ Fevers_____________ Hoarseness in voice_____________ Gagging or Choking when eating or drinking ________________________ Other____________________________________________________

Do you have Allergies: (list them)

“What Happens”

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