Sample, Sammy G ST0001

Background 1234567890


MM/DD/YYYY
MM/DD/YYYY
If retired, also indicate previous occupation

Ordering Information

Referring Physician


Medical Conditions














COVID Status

MM/DD/YYYY
MM/DD/YYYY

COVID-19 Vaccination Record

MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY

Pulmonary Function Test Data


Occupational Exposure


Tobacco Use

Day
Month
Year
_ number of years since quit

Former Cigarette Smoker

Current Cigarette Smoker

Packs/Day (PPD)
Total Pack-Years
1 cig / day = 0.05
2-3 cig / day = 0.10
4 cig / day = 0.20
5 cig / day = 0.25
10 cig / day = 0.50
15 cig / day = 0.75
20 cig / day = 1.00
0 Pack Years

Secondhand Tobacco Smoke Exposure / Occupation


Secondhand Tobacco Smoke Exposure / Household

Your Health in General