• Email:Grafax@gmail.com
    • Phone:480-917-0933
    • Fax:480-917-8866
    • Address:3491 S Mercy Rd. Suite 103,Gilbert AZ.85297
    • MAKE AN APPOINT MENT

Patient Intake

 M F
 Follow up from Hospital. Cough Sputum Production Shortness of Breath Sleep Disorder/Apnea Abnormal CXR (mass, nodule …) Other:
 High Blood Pressure Heart condition High Cholesterol Diabetes Renal failure Thyroid Stroke Seizure Restless leg syndrome Parkinson disease Back pain Arthritis Depression Anxiety Bipolar
 Valley fever COPD Asthma Pneumonia TB Pulmonary Embolism Previous Pulmonary testing:




Family History: (check all that apply)

Family Cancer/Type Lung Disease/Type Heart Disease/Type High Blood Pressure Diabetes
Mother
Father
Siblings

REVIEW OF SYSTEMS: (Check all that apply)

 Weight Gain Weight Loss Poor appetite Fever Night sweats
 Congested Sinuses Runny nose
 Chest Pain Palpitation
 Cough Sputum Production Shortness of Breath Snoring
 Heart Burn Abdominal Pain Indigestion
 Back Pain Joint Pain Arthritis
 Depression Anxiety Bipolar
 Prostate Problems Blood in Urine Bipolar
 Skin Cancer Dry Skin
 Insomnia Head Ache Dizziness
 Easy Bruising Blood Clots Cancer
 Blurred Vision Glaucoma Cataract
 Environmental Allergies Eczema Hay fever Food allergy: HIPPA Privacy act was reviewed