Upper/Lower Respiratory Infection Form

This form is supplied with the questions linked with all the possible infections due to which the respiratory system can be at stake. The form includes the credentials of the patient including name, his/her father’s name, date of birth, age, gender, blood group, current heartbeat, blood pressure both systolic and diastolic, examination details of ear, throat, eyes, nose, heart, chest, etc.  Any current or previous respiratory syndrome diagnosed and the particulars of the doctor who prescribed the test and reason or symptoms for that, the name of the concerned lab, hospital from where the relevant test was done and the result details of the test are asked on this form. Moreover, this comprises any related prescribed medicines by the doctor. If yes then names and dosage of the medicine is asked. If the patient is a smoker or a tobacco/ drug/ steroid afflicted person, then the respective details are demanded. E.g. the frequency/ duration. The details of any past allergic reaction i.e. redness/ itching to  the eyes/ nose or throat, ear/ ear canal, any previous asthmatic test prescribed and the result details of the test is asked that can attribute in finding the disease.

The form requires the details of working place of the patient if he/ she is a professional. This is of significant value as it can prove decisive in determining the root cause of respiratory syndromes as majority respiratory illnesses are contagious being air-borne and the workers of hospitals, labs, schools and crowdy places are more vulnerable to respiratory diseases.

The form has a section for  upper respiratory infections based on questions like if the patient is having any discomforts associated with the upper respiratory tract e.g. throat, nose, lungs, pharynx, larynx, bronchi, e.g. common cold, sneezing, cough, fever, fatigue, wheezing, headache, sinusitis, pharyngitis, epiglottis, tracheobronchitis or similar symptoms like breathing difficulty, sweating, nasal/ chest congestion, difficulty/ pain  in swallowing or a similar discomfort felt or experienced is asked. If the patient is experiencing any of these, he/she will choose the respective disease on the form and fill up the frequency / duration too in the respective field. The form, in addition, demands the past medical histories of the relevant tests and their results details. E.g. the throat swab test, chest X-ray in the case of Pneumonia, CT-scan in the case of Sinusitis, chest pain if felt and the phlegm color if observed and its texture/ viscosity / frequency etc. that can correlate with the clinical findings.


Similarly, the form consists of the information regarding LRTI (lower respiratory tract infections) primarily associated with the Pneumonia, acute bronchitis, etc. If the patient has been ever  afflicted with these or similar infections, diagnosed by the doctor  he/ she can fill out the required fields containing the duration/ frequency and dosage of any medications if prescribed and the credentials of the doctor in this regard and particulars of the respective lab / hospital  that can facilitate the present diagnosis.

For a satisfactory diagnosis of the respiratory disorders, the patient must carefully read and abide by the instructions and principles on the form and accede to the terms and conditions and provide all the concerned particulars.

Respiratory infection record form

DOWNLOAD: Respiratory Infection Record Form

Simi Karton

Simi Karton is a regular contributor to National Science Quarterly and an enthusiastic Lakers fan. She recently collaborated on a manuscript with friends and colleagues. Dr. Simi Karton, entitled Parkinsons and the Genetic Response to Eastern Medicine, in which she and Dr. Inshal presented research compiled during a summer spent in United States. She currently resides in Los Angeles with her husband. This website is a voluntary work of Dr. Karton to provide people with useful health related information stuff at an easy approach. The information has been collected from different sources at one place.

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