RESPIRATORY REPORT



PATIENT:_________________________________________________
SOCIAL SECURITY #:_______________________________________
DATE OF BIRTH:____________________________________________________

Dear Doctor,
Please answer the following questions with regard to your patient's claim for Social Security disability benefits. Please base your answers on how your patient's medical conditions affect his/her ability to function.

1.When did you first examine this patient? _____________________

Date of most recent examination: ___________________

Height: ______________ Weight: ________________

2.
Diagnosis: __________________________________________

(Please list any related diagnoses):




3.Date of onset of Condition: _______________________

4.
Clubbing: __________________________ Cyanosis: __________________________

Orthopnea: _____________________________

5.
Results and date of recent chest x-ray:




6.Pulmonary function test performed: (Please either fill in or attach test results)
Date: ____________________
 a)Were these studies performed during bronchospasm of wheezing? Yes _____ No _____
 b)Was a bronchodilator used during testing? Yes _____ No _____
If so, please provide the pre and post bronchodilator values:




 c)Vital capacity (predicted value): ___________________
                           (actual value): ___________________
 
d)
FEV 1 (predicted value): ___________________
                (actual value): ___________________
 
e)
MVV (predicted value): ___________________
                (actual value): ___________________

7.
Date and results of blood gas studies?




8.For Asthmatic Attacks please describe:
 a)          Frequency                                Number
  ___________________daily_____________________
  ___________________weekly___________________
  ___________________monthly___________________
 
b)
Duration of attacks: Hour(s) _______________ Day(s) ________________
 
c)
Has the patient required hospitalization for attacks? Yes _____ No ______
If yes, please provide the following:

Date(s)                     Hospital                                 Emergency Room Only?
 
                                                                                          Yes ______
                                                                                           Yes ______
                                                                                           Yes ______
                                                                                           Yes ______
 
d)
Treatment required in Emergency Room or Hospital (please indicate):
  1. Medication: __________________________________
  2. Oxygen: _____________________________________
  3. Bronchodilator: ________________________________
  4. Other: _______________________________________

9.
Does your patient exhibit any of the following clinical signs between acute respirator episodes?
WheezingYes _____ No _____
CoughingYes _____ No _____
Shortness of BreathYes _____ No _____
RonchiYes _____ No _____
Prolonged expirationYes _____ No _____
Dizziness/FatigueYes _____ No _____
Unable to catch breathYes _____ No _____
Other (Please describe)_______________________________________________

10.
Therapy (Please describe and list medications):






11.
Do you consider this condition:
 Well controlled __________________________
 Under control ___________________________
 Poorly controlled ________________________
 Other _________________________________

12.
Does this condition restrict your patient's activities?
(Please indicate for each activity below)
  Not at allAs AbleLimited to
X minutes
(Please
Specify Mins)		With HelpNormal
A.Housework     
a.washing dishes______________________________
b.vacuuming______________________________
c.dusting______________________________
d.sweeping______________________________
e.making bed______________________________
f.cooking______________________________
g.washing clothes______________________________
B.Yard Work     
a.shoveling snow______________________________
b.cutting grass______________________________
c.gardening______________________________
d.raking leaves______________________________
e.other __________________________________________
C.Transportation     
a.driving a car______________________________
b.riding a bus______________________________
c.walking______________________________
D.Work Environment     
a.commuting______________________________
b.standing______________________________
c.smoke or dust______________________________
d.walking______________________________
e.other work
activity
Specify ________________		______________________________

13.
Is your patient able to work 8 hours a day? Yes _____ No ______
(Please explain):




14.Is your patient restricted in any other way?




15.Do you expect your patient's condition to improve or degenerate? __________________
If it will improve, how soon? ___________________________

16.
Other comments regarding this problem or the claimant's general medical condition:





Signature: ______________________________
Name: (Print) ______________________________
Address: ______________________________
______________________________
Telephone: ______________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357