| Respiratory History | Yes / No | 
| Do you have seasonal allergies? | Y | 
| Do you ever cough up blood? | N | 
| Do you have a morning cough? | N | 
| Do you produce sputum with the cough? | N | 
| If so, what color? | N/A. | 
| How many pillows do you sleep on? | 1 | 
| Have you had a flu vaccine? | N | 
| Have you had a pneumonia vaccine? | N | 
| When was your last chest x-ray? | N/A |