Terms and Conditions
U-Breathe is collecting and using your personal information such as: Name, e-mail address, and any additional information which you provide for the purpose of providing health services including the most comprehensive and timely care (HIA section 20(b)). The information provided will remain confidential within U-Breathe and never be shared with third parties. Data collected from this form will not be stored on the website and is destroyed after it is used. The collection of your personal information is authorized by section 33(1)(c) of the Freedom of Information and Protection of Privacy Act. Any questions concerning the collection, use or disclosure of your personal information may be directed to U-Breathe at 1-403-475-9766. You may also write to U-Breathe: Suite 205, 4411 16 Ave NW, Calgary AB, T3L 3E6 Or email us at clinic@u-breathe.ca Click on the “I Understand” checkbox below to confirm your acceptance. By doing so, you are indicating that you have read and understood these terms and conditions and you are providing U-Breathe with consent to collect and use your personal information as indicated above.
I Understand
New Patient Questionnaire
Please answer the following questions to the best of your ability. If you do not understand the question or need help answering it, you may skip it and proceed to the next one. These questions will help us provide the best and most comprehensive assessment of your breathing concerns.
Your Name
Your Email
Your Year of Birth (i.e. 1940)
Have you ever been diagnosed with asthma? YesNo
Has anyone in your family been diagnosed with asthma? YesNo
Have you ever been diagnosed with COPD? YesNo
Have you ever been diagnosed with a lung condition? YesNo If yes, what condition?
Have you had an allergy test in the past? YesNo
Do you have any allergies to the environment? (Pollens, trees, grasses…) YesNo
How often do you have a runny or stuffy nose? RarelyA few times per weekDailyConstantly
Do you frequently clear your throat? YesNo
Have you had a sinus infection in the past year? YesNo
Have you ever been diagnosed with nasal polyps? YesNo
Have you ever had any surgeries on your nose? YesNo
How many times do you get sick with a cold or flu in a year? 0 - 1 times per year2 - 3 times per year4 - 6 times per year6 or more times per year
Have you ever had pneumonia or a serious lung infection? YesNo
Have you ever been hospitalized for your breathing? YesNo
Have you ever been sick with or exposed to tuberculosis (TB)? YesNo
Do you get the flu vaccine/flu shot yearly? YesNo
Have you had the pneumonia vaccine within the past 10 years? YesNo
Please indicate the option that is most applicable to you: 1. I am not troubled by breathlessness except with strenuous exercise2. I become breathless when hurrying on level ground or up a slight hill3. I walk slower than other people of the same age on level ground because of breathlessness, I have to stop to catch my breath when walking at my own pace on level ground.4. I must stop to catch my breath after walking about 100 yards or a few minutes on level ground.5. I am breathless when dressing/undressing or performing my daily activities, I may be too breathless to leave the house.
Out of the following, please select all those that apply to you: snore loudly at nightfeel tired in the morning or not well rested after sleep.wake up at night gasping for air.been witnessed to stop breathing at night.regularly take daytime naps.completed a sleep test or sleep study.diagnosed with sleep apnea.
Have you ever smoked cigarettes? YesNo
If yes, what year did you start smoking? If yes, Average number of cigarettes smoked per day: If yes, what year did you quit smoking? (if applicable)
Have you ever smoked marijuana regularly? YesNoPrefer Not to Answer
Have you ever vaped regularly? YesNoPrefer Not to Answer
Do you drink alcohol regularly? YesNoPrefer Not to Answer
Is there any other recreational drug use? YesNoPrefer Not to Answer
Is there carpeting in the bedroom? YesNo Do you have a hot tub or a standing pool of water? YesNo Are there any pets in the house? YesNo If yes, What animal and how many? (ie. 2 dogs) If yes, how long have you been around pets? (ie. 2 years)
What is your current or previous occupation, and for how long? (ie. electrician for 10 years) Was there any exposure to hazards that could harm your lungs from work? (I.e. asbestos, fumes, chemicals, grain dust, mold, metal dust, …)
Were there any exposures to hazards or irritants in the home?(I.e. asbestos, mold, wood dust, potted plants, …)
Have you travelled outside of Canada in the last 2 years? YesNo
Out of the following, what would make your breathing get worse: sick with a cold or flustress or strong emotionsbeing around fire smokebeing around tobacco smokebeing around strong odours or perfumesbeing in cold airweather changesexercisebeing around fresh cut grass or weedsbeing around pollensbeing around a dusty areabeing around moldbeing around animals such as cats, dogs, horses, mice, rabbits, birds or feathers
Do you have any chronic medical conditions? (Please list) Hypertension,GERD,Eczema,Stroke,Lupus Or Connective Tissue Disorder,Ulcerative Colitis Or Crohn’s,Arthritis,Atrial Fibrillation,Cancer,Pneumothorax,Gout,Glaucoma,Pleurisy/Pleural Effusion,Pulmonary Embolus/Clot in The Lungs,Heart Attack/Myocardial Infarction,Heart Failure,Coronary Artery Disease,Other (please list below)
Other chronic medical conditions: (optional)
Have you had any surgeries in the past? (Please describe)
Please describe the problem or question about your breathing that you would like the lung specialist to address during the visit:
Please let us know if you have any additional comments: (optional)
