Respiratory Assessment Form
Respiratory Assessment Form
Please fill out this form completely to assess your respiratory health and provide the necessary information for further evaluation.
Personal Information
Name
Age
Gender
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Male
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Female
-
Phone number
Medical History
Do you have a history of respiratory conditions? (e.g., asthma, COPD, etc.)
If yes, please specify
Current Symptoms
Please check all symptoms you are currently experiencing
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Shortness of breath
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Persistent cough
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Wheezing
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Chest tightness
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Are you currently taking any medication for respiratory issues?
If yes, please list
Lifestyle Factors
Do you smoke?
If yes, how many years have you smoked?
Do you have regular exposure to pollutants or chemicals?
If yes, please specify
Emergency Contact
Name
Phone number
Please check the box below to proceed
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