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Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
Blog
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Online Appointment
Online Appointment
online Appointment
Forms
Medical History
FORMS
Fill all required fields (★) to submit the form.
Patient details:
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number:
(Required)
Home Phone:
Address:
Email Address:
(Required)
Smoking History:
(Required)
Current
Previous
Passive smoking
Never smoked
Start:
(Required)
Stop:
(Required)
Number of cigarettes per day:
(Required)
Alcohol:
How frequent:
How many drinks:
Job(s):
Past:
Current:
Specific occupational exposure:
Weight:
Weight:
Stable
Gain (kg):
Loss (kg):
Current medications:
Past medical history:
Pets at home:
No
Yes
Details about live:
Asbestos exposure:
No
Yes
Snoring:
No
Yes
Motor vehicle accidents associated with sleepiness in the past?
No
Yes
Feeling tired/sleepy during the day?
No
Yes
Respiratory symptoms:
Cough
Phlegm
Wheeze
Shortness of breath
Chest Tightness
Other:
Live:
Alone
With
Relationship
Confirm:
(Required)
I agree that I have answered these questions to the best of my ability.
(Required)
