CQRASC Respiratory History Form "*" indicates required fields Patient InformationName* First Name Last D.O.B* DD slash MM slash YYYY Age*Gender* Male Female Other Collar Size*Weight*Height*Smoking* Yes No If yes, Age StartedNumber a DayAlcohol* Yes No Spirits / LagerNumber a WeekDriving* Yes No Type of LicenseCurrent ProblemsCough* Yes No Chest Pain* Yes No Wheeze* Yes No Breathlessness* Yes No Weight Loss* Yes No Back Pain* Yes No Night Sweat* Yes No Coughing Blood* Yes No Existing Medical HistoryAsthma* Yes No Restricted Airflow or Breathing Problems* Yes No Diabetes* Yes No Hypertension* Yes No Heart Problems* Yes No Acid Reflux* Yes No Anxiety/ Depression* Yes No Others (Including Surgeries / Previous Cancers)Pneumonia When Young* Yes No Measles* Yes No Whooping Cough* Yes No TB* Yes No Family History of Heart and / or Lung Problems* Yes No Current Medications (Including Over the Counter Treatment)*Allergies*PetsBirds Yes No Dog Yes No Cat Yes No Other Yes No Living CircumstancesType of PropertyBrick HouseQueenslanderLow Rise HouseEvidence of Dampness in the Property Yes No Carpet Yes No Occupation(List of jobs since starting work and the intensity of dust exposure). Please name the Companies and duration.Date* DD slash MM slash YYYY
