Respiratory Assessment Form

Respiratory Assessment Form — Form Fields

This healthcare template includes 8 fields. Respiratory assessment form for evaluating lung function, breathing patterns, and respiratory symptoms. Designed for pulmonology clinics, respiratory therapists, and emergency departments. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Primary Respiratory Complaint (dropdown selection, required) — options: Chronic cough, Shortness of breath, Wheezing, Chest tightness, Excessive sputum production, Sleep apnea symptoms, Other
• How long have you had these symptoms? (dropdown selection, required) — options: Less than 1 week, 1-4 weeks, 1-3 months, 3-12 months, More than 1 year
• Smoking Status (multiple choice, required) — options: Never smoked, Former smoker, Current smoker, Vape / e-cigarette user
• Known Respiratory Conditions (select all that apply) (checkboxes, optional) — options: Asthma, COPD / Emphysema, Pulmonary fibrosis, Pneumonia (recent), Lung cancer, None diagnosed
• Do you use supplemental oxygen? (multiple choice, required) — options: Yes, continuously, Yes, as needed, No
• Do you use an inhaler? (multiple choice, required) — options: Yes, rescue inhaler only, Yes, maintenance and rescue, No
• Additional Symptoms or Notes (long text, optional)