Doctor Visit Worksheet


Answer these questions, then click print below. We'll create a customized guide to help you get the most out of your next visit.

You must answer all questions completely.

1. Do breathing problems slow you down?
Yes  
No
2. What symptoms have you been experiencing recently?
  • Persistent cough
  • Coughing up phlegm or mucus
  • Shortness of breath during activities
  • Wheezing or whistling when you breathe
3. Do you have any other medical conditions?
Yes  
No
4. What medications are you currently taking?
 (Please list all your medications, even eye drops)
5. What's your smoking history?
  • Never smoked
  • Used to smoke, but quit
  • Are trying to quit
  • Still smoke
6. How often do you exercise a week?
  • 0 times
  • Once or twice
  • 3 or 4 times
  • 4 or more times
7. About how often do you use a rescue inhaler, like albuterol, to help your breathing?
  • Never use one, don't have a prescription
  • 0-1 time a week
  • A few times a week
  • About once a day
  • 2-3 times a day
  • 4-6 times a day
  • More than 6 times a day
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