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Lung Testing Form Data

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Registration
(Please Print)

Dr Talha Memon M.D
39755 Date St Ste. 101
Murrieta, CA 92563

Tel : (951) 698 - 6629
Fax : (951) 698 - 8732

Patient (Last, First, MI) :

Date :

Cell Phone :

Home Phone :

Mailing Address :

City :

ZIP :

Sex :

Birthdate :

Email Address :

Medical Insurance :

ID# :

Group# :

SSN :

Spouse's SSN (if used for billing) :

Secondary Medical Insurance :

Secondary ID# :

Secondary Group# :

Please list people we may discuss your Medical/Financial Record with, how they are related to you, and their Contact Information.

Insurance Assignment and Release

I Certify that I have insurance coverage with

and assign directly to Dr Talha Memon all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance.

I authorize the use of my signature on all insurance submissions. the above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Medicare Authorization I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr Talha Memon DBA Complete Sleep Solutions for any services furnished to me by that provider. To the extent permitted by law, I authorize any holder of medical or other information about me to release to the Centers for Medicare and Medicaid Services and their agents any information needed to determine these benefits or benefits for related services.

Signature :

Print Name :

Date :

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I understand and/or have received and/or been offered a copy of this medical practice's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that i will be offered a copy of any amended Notice of Privacy Practices at each appointment. (Signing below means we will not release your medical records to anyone without your written consent)

Signature :

Date :

Print Name :

If not signed by patient, please indicate relation :

Please follow these instructions in preperation for your test.

Take any blood pressure medicines, insulin, antidepressants, cholesterol medicine and non-breathing related medicines if this is something you normally do.
If you take pills or inhaled steroids (QVAR, Pulmicort, Flovent, Asmanex, Arnuity) you may continue to take then as usual.

24 hours before test: Stop all long acting bronchodilators

Serevent
Advair
Foradil
Spiriva
Symbicort

Brovana
Incruse
Breo
Anoro
Bevespi

Stiolto Respimat
Dulera
Tudorza
Oral Theophylline

6 hours before test: Stop all inhaled and tablet form short acting bronchodilators

Primatene Tablets
Albuterol Tablet
Brethine Tablet

Xopenex
Atrovent
Combivent

Duoneb
Albuterol (ProAir, Proventil, Ventolin)
Maxair

Activities that should be avoided prior to testing

Stop smoking at least 4 hour before test.
No alcohol within 4 hours of testing
No vigorous excercise within 30 minutes of testing
Do not wear tight clothing that makes it difficult for you to take a deep breath
Eating or Drinking within 2 hours of testing (a few sips of water are fine)
No caffeine within 4 hours of testing
No lipstick

Please bring in your authorization paperwork and/or RX from your doctor. It should have a written order for testing and suspected diabnosis. You must have this if your doctor gave it to you or we cannot administer the test. Please arrive early with paperwork completely filled out.

YOU WILL NOT BE SEEING DR. HENNINGER DURING THIS TESTING SESSION.

PFT Questionaire

FULL NAME : Fuad Jaleel Ahmed

Date : 2020-02-10

Referring Physician :

Sex : M

Date of Birth : 1987-05-05

Height : 6.0

Weight : 88kg

Race : Asian

Ethnicity : Other

Preferred Language : English

Reason for Testing : Shortness of Breath

Is this Pre-Op?No

What surgery is planned?

Previous Pulmonary Test?No

When/Where?

Smoking History : Current-Smoker

Ex-Smoker : Packs/Day

For : Years

and Quit in :

Current Smoker : 1 packs/day

for : 12 Years

Occupation : web developer

Exposures at work or in daily living? Other

Other :

Recent Respiratory Illness within last 6 wks? : None

Do you currently Use?

Other Meds that can effect lung function :

PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU

Used a short acting or "rescue" inhaler within the last 6 hrs?	No
Used a long acting "maintainence" inhaler within the last 24 hrs?	No
Used bronchodilators pills within the last 8 days?	No
Smoked within last 6 hrs?	Yes
Had any caffeine containing food/drink within last 6 hrs?	Yes

YOUR CARDIO-PULMONARY & SLEEP HISTORY :

Shortness of Breath with regular activities or with excertion only - Chronic Cough with mucus - Restless Legs -

PLEASE LIST ANY & ALL ALLERGIES :

PLEASE LIST YOUR CURRENT MEDICATIONS :

FAMILY HISTORY :

Diabetes

Document Photos

Insurance Card Front

Old Form Data, Photo not available.

Insurance Card Back

Old Form Data, Photo not available.

Driving Licence

Old Form Data, Photo not available.

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Questionaire Forms

Lung Testing Form Data

Additional Info

Acknowledgement of Receipt of Notice of Privacy Practices

YOU WILL NOT BE SEEING DR. HENNINGER DURING THIS TESTING SESSION.

PFT Questionaire

PRIOR TO THIS SCHEDULED PFT TESTING, HAVE YOU

YOUR CARDIO-PULMONARY & SLEEP HISTORY :

PLEASE LIST ANY & ALL ALLERGIES :

PLEASE LIST YOUR CURRENT MEDICATIONS :

FAMILY HISTORY :

Document Photos

Insurance Card Front

Insurance Card Back

Driving Licence

Write Report

All Reports