PATIENT INFORMATION Please print clearly and complete all blanks DATE: REFERRED BY: SEX:

NAME: BIRTHDATE: LAST FIRST MIDDLE

MAILING ADDRESS: CITY STATE ZIP

TELEPHONE: CELL PHONE: WORK NUMBER:

SS # MARITAL STATUS: EMAIL:

EMPLOYER: OCCUPATION:

EMPLOYER’S ADDRESS:

************************************************************************************************************ RACE (circle one): AMERICAN INDIAN – ALASKAN – ASIAN – BLACK – WHITE – HISPANIC

SMOKER STATUS (circle one): EVERY DAY – SOME DAYS – FORMER – NEVER

RELIGION:

************************************************************************************************************ NEXT OF KIN: BIRTHDATE:

ADDRESS IF DIFFERENT: ADDRESS CITY STATE ZIP CODE

RELATIONSHIP: MALE FEMALE TELEPHONE:

************************************************************************************************************

EMERGENCY CONTACT:

ADDRESS IF DIFFERENT: ADDRESS CITY STATE ZIP CODE

RELATIONSHIP: MALE FEMALE TELEPHONE:

************************************************************************************************************

RESPONSIBLE PARTY FOR BILLING (if other than patient):

RELATIONSHIP

NAME: TO PATIENT:

ADDRESS: ADDRESS CITY STATE ZIP CODE

SS #: BIRTHDATE TELEPHONE:

************************************************************************************************************

PRIMARY INSURANCE: ID#: GROUP#

NAME OF INSURED: INSURED’S BIRTHDATE:

SECONDARY INSURANCE: ID# GROUP#

NAME OF INSURED: INSURED’S BIRTHDATE:

REV 2017.03.28 FORM#:TCH_FGMC005.11.ai

SIGNATURE: DATE:

All professional services rendered are charged to the patient’s account. Necessary forms will be completed to expedite insurance claims for those plans which the

physician files. The patient is responsible for all fees, regardless of insurance coverage.

I hereby assign to the physician all payments for medical services rendered and authorize the physician to release any medical information necessary to process claims

and request payments from insurance companies or Medicaid payers. A photocopy of this assignment and authorization shall be considered as valid as the original.

Name:__________________________________________ Date:_______________________

Please mark all that apply YES NO

Do you snore □ □ Have you been told you stop breathing at night □ □

Anxiety/Depression □ □

High Blood Pressure □ □

Restless Sleep □ □

Trouble concentration and/or forgetfulness □ □

Loss of Libido □ □

Short temper and/or Irritability □ □

Fatigue □ □

Loss of energy □ □

Are you Diabetic □ □

Morning Headaches □ □

Do you fall asleep at inappropriate times □ □

Epworth Sleepiness Scale How likely are you to doze-off or fall asleep in the following situations, in contrast to just feeling tired? This

refers to your usual way of life in recent time. Even if you have not done some of these things recently, try to

work out how they would have affected you.

Use the following scale to select the most appropriate number for each situation.

0-Would never doze 1-Slight chance of dozing 2-Moderate chance 3-High Chance

SITUATION CHANCE OF DOZING

Sitting and reading a book or magazine _____

Watching television or a movie at home _____

Sitting, inactive in a public place (theatre or meeting) _____

As a passenger in a car for an hour without a break _____

Lying down to rest in the afternoon when time permits _____

Sitting and talking face-to-face with someone _____

In a car, while stopped for a few minutes in traffic _____

Total: _____

Sleep Evaluation in Primary Care

Please complete the following: 6. How often do you feel tired or fatigued after

Height_________ Age_____________ your sleep?

Weight________ male/female______ □ nearly every day

□ 3-4 times a week

1. Do you snore? □ 1-2 times a week

□ yes □ 1-2 times a month

□no □ never or nearly never

□ don’t know

If you snore 7. During your waketime, do you feel tired, fatigued or

2. Your snoring is? Fatigued or not up to par?

□ slightly louder than breathing □ nearly every day

□ as loud as talking □ 3-4 times a week

□ louder than talking □ 1-2 times a week

□ very loud. Can be heard in adjacent rooms □ 1-2 times a month

□ never or nearly never

3. How often do you snore? 8. Have you ever nodded off or fallen asleep while

□ nearly every day driving a vehicle?

□ 3-4 times a week □ yes

□ 1-2 times a week □ no

□ 1-2 times a month

□ never or nearly never if yes, how often does it occur?

□ nearly every day

4. Has your snoring ever bothered other people? □ 3-4 times a week

□ yes □ 1-2 times a week

□ no □ 1-2 times a month

□ never or nearly never

5. Has anyone noticed that you quit breathing

during your sleep? 9. Do you have high blood pressure?

□ nearly every day □ yes

□ 3-4 times a week □ no

□ 1-2 times a week □ don’t know

□ 1-2 times a month

□ never or nearly never 10. BMI>30

□ yes

□ no

Name ________________________________

Address ______________________________

_____________________________________

The Modified Medical Research Council (MMRC) Dyspnea Scale

Grade of

dyspnea Description

0 Not troubled by breathlessness exept on strenuous exercise

1 Shortness of breath when hurring on the level or walking up a slight hill

2 Walks slower than people of the same age on the level because of breathlessness

or has to stop for breath when walking at own pace on the level

3 Stops for breath after walking about 100 m or after a few minutes on the level

4 Too breathless to leave the house or breathless when dressing or undressing

COPD Assessment Test Of Tahlequah

Name: __________________________________________ Date: ______________________

How is your COPD? Take the COPD assessment test

This questionnaire will help you and your healthcare professional measure the impact COPD

(Chronic Obstructive Pulmonary Disease) is having on your wellbeing and daily life. Your

answers, and test score, can be used by you and your healthcare professional to help improve

the management of you COPD and get the greatest benefit from treatment.

For each item below, place a mark (X) in the box that best describes you currently. Be sure to

only select one response for each question.

Example: I am very happy ⓪①②③④⑤ I am very sad Score

I never cough ⓪①②③④⑤ I cough all the time _____

I have no phlegm (mucus) ⓪①②③④⑤ My chest is completely

In my chest at all full of phlegm (mucus) _____

My chest does not ⓪①②③④⑤ My chest feels

Feel tight at all very tight _____

When I walk up a hill or ⓪①②③④⑤ When I walk up a hill or

one flight of stairs I am one flight of stairs I am

not breathless not breathless _____

I am not limited doing ⓪①②③④⑤ I am very limited doing

any activities at home activities at home _____

I am confident leaving ⓪①②③④⑤ I am not at all confident

my home despite my leaving my home because

lung condition of my lung condition _____

I sleep soundly ⓪①②③④⑤ I don’t sleep soundly

Because of my lung condition _____

I have lots of energy ⓪①②③④⑤ I have no energy at all _____

Total Score _____

ASTHMA CONTROL TEST Of Tahlequah

Name: __________________________________________ Date: ______________________

The Asthma Control Test provides a numerical score to help you and your healthcare provider

determine if you asthma symptoms are well controlled.

Take this test if you are 12 years or older.

Step 1: Write the number of each answer in the score box provided

Step 2: Add up each score box for the total.

SCORE

1. In the past 4 weeks, how much of the time did your asthma keep you from

getting as much done at work, school or at home?

All of Most of Some of A little None of

the time(1) the time(2) the time(3) the time(4) the time(5) _____

2. During the past 4 weeks, how often have you had shortness of breath

More than Once 3 to 6 times Once or Not at all(5)

Once a day(1) a day(2) a week (3) twice a week(4) _____

3. During the past 4 weeks, how often did your asthma symptoms (wheezing,

Coughing, shortness of breath, chest tightness or pain) wake you up at night

or earlier than usual in the morning?

4 or more 2 to 3 nights Once a Once or Not at all(5)

Nights a week(1) a week(2) week(3) twice(4) _____

4. During the past 4 weeks, how often have you used your rescue inhaler or

Nebulizer medication (such as albuterol)?

3 or more 1 or 2 times 2 or 3 times Once a week Not at all(5)

Times per day(1) per day(2) per week(3) or less(4) _____

5. How would you rate your asthma control during the past 4 weeks?

Not controlled Poorly Somewhat Well Completely

At all (1) Controlled(2) Controlled(3) Controlled(4) Controlled(5) _____

Total _____

MEDICATION SUMMARY

PATIENT _____________________________________________________________ DOB _______/_______/_______

PHARMACY _____________________________________________PHARMACY PHONE # ___________________

ALLERGIES __________________________________________________________________________________________

________________________________________________________________________________________________________

START

DATEMEDICATION/STRENGTH DIRECTIONS PRESCRIBED BY