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Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out - page 4 / 8

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

Appointment Date:___________________ Name:_____________________________ DOB:__________________

Have you had the following done?

Breathing Test (when/where)________________

Chest x-ray (when) _____________________

CAT SCAN (when)_________________________

Cardiac Stress test (when)________________

Heart Catheterization (when)_________________

2-D Echocardiogram (when)_______________

Pneumonia Vaccine (when)___________________

Flu Vaccine (when)______________________

Tuberculosis Exposure (when)________________

Last Skin test (positive/negative)___________

Pneumonia

COPD/Emphysema

Asthma

Diabetes

Past Medical Problems: (circle) High Blood Pressure

Heart Disease

Cancer (when/where) ____________________

Other

_________________

Surgeries or Hospitalizations (Please List) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Family History: List any health problems

Father: (Living /Deceased) ____________________________ Mother: (Living / Deceased)___________________________ Brothers/Sisters: (Living /Deceased)_____________________ Children (Living / Deceased)___________________________

Habits: Do you do any of the following? Smoke Cigarettes/ Cigars How many a day ______

How many years

______Quit, when

_____

Chew Tobacco _____________ Use any other Drugs ________________________________ Alcohol: Type / How much a day or week? ________________________________________

Occupation/ Retired/ Disabled ____________________________________________

Occupational Exposure: (Asbestos, Chemicals, Fumes, Dust, Fibers, Metals, Radiation) Coal Miner, Welder, Factory, Farmer, Grinder: __________________________________________________________________________ Pets: (inside/outside) / Any Birds? ______________________________________________ Blood Transfusion (when /why)_________________________________________________

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