Respiratory intake with the depth pulmonology needs — symptoms, exposures, and smoking history.
Healthcare template · 14 fields (4 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Pulmonology assessment lives on history: respiratory symptoms and their pattern, dyspnea severity, smoking history in pack-years, occupational and environmental exposures, known pulmonary conditions, and prior testing. This form structures that history as checkbox inventories and standardized ratings, because in respiratory medicine the unasked question is the missed diagnosis.
The exposures inventory deserves particular attention — occupational lung disease is routinely missed because nobody asked about the twenty years in the machine shop. Here it is a required part of the record, not an afterthought.
Best practices
Send the form ahead of the visit; pack-year math and exposure timelines are far more accurate when patients answer at home.
Cross-check the previous-tests inventory before ordering — duplicate pulmonary function tests are common when prior records live in another system.
Dyspnea severity captured on a standardized scale at every visit gives you the trend line that free-text notes never produce.
Treat the exposures checklist as a screening instrument: any positive answer earns a follow-up question about duration and protection.
Every field, explained
Patient Name (Name, required)
Date of Birth (Date, required)
Chief Complaint (Long text, required)
Respiratory Symptoms (Multiple choice)
Shortness of Breath Severity (Single choice) — A standardized breathlessness rating; its trend across visits is the clinical signal.
Smoking History (Multiple choice)
Pack-Years (if applicable) (Short text) — Packs per day times years smoked — the standardized exposure number screening guidelines key on.
Occupational/Environmental Exposures (Multiple choice) — Occupational and environmental — asbestos, silica, birds, mold. The most under-asked question in respiratory intake.
Known Pulmonary Conditions (Multiple choice)
Current Respiratory Medications (Long text)
Exercise Tolerance (Single choice, required)
Previous Pulmonary Tests (Multiple choice) — Prevents duplicate ordering and tells you what baseline data already exists.
Family History of Lung Disease (Multiple choice)
Additional Symptoms or Concerns (Long text)
Frequently asked questions
What does a pulmonology assessment form cover?
Respiratory symptoms, dyspnea severity, complete smoking history with pack-years, occupational and environmental exposures, known pulmonary conditions, current respiratory medications, exercise tolerance, prior testing, and family history — the full history a respiratory evaluation is built on.
Why does the form ask about occupational exposures?
Because occupational lung disease is one of the most missed diagnoses in respiratory medicine — symptoms surface decades after exposure, and patients rarely connect the two. A structured exposure inventory makes the question systematic instead of dependent on someone remembering to ask.
Is this pulmonology form HIPAA compliant?
The template is HIPAA-ready: on a HIPAA-enabled plan, submissions are encrypted, access-controlled, audit-logged, and covered by a Business Associate Agreement.
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