New Patient History — Please answer every question.
PATIENT'S FIRST NAME       PATIENT'S LAST NAME
PATIENT'S DATE OF BIRTH (month) - (day) - - Enter year (ie: 1932)  (mm-dd-yyyy)      
GENDER:  
 Male Female
What are your main concerns today?
  cough congestion runny nose
  post-nasal drip nasal itch eye itch
  tearing sneezing eczema
  hives rash vomiting
  exercise problems wheezing chest pain
  shortness of breath headache earache
  sinus pain sore throat other
Have you been diagnosed, or do you medication reaction asthma nasal allergy
suspect that you have any of the stinging insect reactions eczema latex allergy
following: recurrent infections hives food allergy
  IVP/x-ray dye allergy aspirin/Advil/NSAID allergy
      sulfite/sulfur dioxide (not sulfa drug) allergy
Asthma
Has asthma been a problem?
no (Mark here then skip to Nasal Allergy/Hay Fever)
 yes
Age of asthma onset less than 1 1-3 4-10
  11-20 21-40 over 40
Trend of asthma severity unchanged improving worsening
Symptom frequency daily weekly monthly
quarterly yearly none
Activity limitation occurs daily weekly monthly
quarterly yearly none
Sleep disturbance occurs daily weekly monthly
quarterly yearly none
Days of work/school missed per year 0 1-5 6-10
  11-20 21-30 over 30
(Caretaker) Days of work missed due to child's asthma per year N/A 0 1-5
  6-10 11-20 over 20
Sick visits to the doctor or ER visits per year for asthma flares 0 1-2 3-5
  6-10 over 10    
Steroid (eg. Prelone, Pediapred, Prednisone) bursts or steroid shots per year 0 1-2 3-5
  6-10 over 10    
Hospitalizations for asthma (total) 0 1-2 3-5
  6-10 11-20 over 20
Intensive care admissions (total) 0 1-2 3-5
  6-10 over 10    
Previous chest X-ray
normal
 abnormal none
Previous lung function tests
normal
 abnormal none
Asthma Symptoms
  no symptoms chest pain cough
  chest tightness night cough cough w/exercise
  shortness of breath night awakening wheezing
Asthma Triggers
  weather changes exercise fumes
  work or school infections laughing
  indoor activities musty areas pets
  outdoor activities smoke cold air
Seasonal Pattern year round spring summer
Mark worst season(s) and whether or not year round fall winter    
Nasal Allergy/Hay Fever
Have nasal/sinus allergies been a problem?
no (Mark here, then skip to Environmental History)
 yes
Age of allergy onset less than 1 1-3 4-10
  11-20 21-40 over 40
Trend of allergy symptoms unchanged improving worsening
Nasal Symptoms
  nasal itch runny nose post nasal drip
  sneezing stuffiness mouth breathing
  sniffling snoring cough
Eye symptoms dark circles itching puffiness
  redness tearing    
Allergy triggers cats dogs dusting/vacuuming
  smoke gardening indoor activities
  school/work musty areas outdoor activites
Seasonal pattern year round spring summer
  fall winter    
Allergy Testing and Treatment
Previous allergy testing none skin test RAST (allergy blood test)
Positive reactions none dust mites cats
  dogs cockroaches molds
  grasses trees weeds
Has patient received allergy shots     yes no
Shots were effective yes no uncertain
Duration of allergy shots less than 1 year 1-3 years 4-5 years
over 5 years        
Allergy shot reactions no large local reaction systemic reaction
Environmental History
Housing house apartment mobile home
  duplex 2nd home condo
Foundation basement pier and beam slab
  other        
Air conditioning none window units central
  evaporative cooler        
Heating none wood stove central hot air
  kerosene electric space heaters    
Indoor mold none AC vents bathroom
  window frames walls Christmas tree
Water damage none plumbing leaky roof
  musty odors condensation water stains
Pets none cats dogs
  birds hamsters gerbils
  rabbits guinea pig other
Pests none roaches    
  rats mice    
Tobacco smoke exposure none parents spouse/partner
  grandparent caretaker other
Bedroom carpet ceiling fans humidifier
  pets in bedroom        
Bed crib mattress waterbed allergy mattress cover
  stuffed toys wool blanket down pillow/comforter/feather bed
  allergy pillow cover air bed standard mattress
Outdoor environment none of these cats dogs
  horses rabbits barn
  compost pile cattle stable
Daycare - Teens/Adults Skip to Eczema
Attendance N/A attends daycare attends elementary school
Class size 1-5 6-10 11-20
over 20        
Smokers yes no    
Pets yes no    
Eczema (skin rashes)
Has eczema been a problem?
no (Mark here, then skip to Hives/Rashes)
 yes
Eczema began at age 0 - 6 months 7-12 months 1-5 years
6-15 years 16-20 years over 20 years
Frequency of symptoms daily weekly monthly
every few months yearly none
Eczema triggers weather changes food seasons
  soap/shampoo clothing dust
  other none    
Hives/Rashes
Have hives/rashes been a problem?
no (Mark here, then skip to Food Allergy)
 yes
Hives/rashes began how long ago less than 6 wks ago 6 wks - 6 mo 6 mo - 1 yr
1-5 years 5-10 years over 10 yrs ago
Hives/rashes occur daily weekly monthly
every few months yearly none
Hives/rashes persist for under 24 hours 1-3 days 4-7 days
1-3 weeks 4-6 weeks over 6 weeks
Food Allergy
Have food allergies been a problem?
no (Mark here, then skip to Stinging Insect Reactions)
 yes
Food allergy symptoms hives/welts swelling wheezing
  mouth/throat itch cough vomiting
  anaphylactic shock diarrhea eczema
Problem foods include milk soy egg
  wheat peanut tree nut
  fish shell fish other
Stinging Insect Reactions
Have stinging insect reactions been a problem?
no (Mark here, then skip to Infection History)
 yes
Stings causing reactions ants bees hornets
  wasps yellow jackets
Reactions large swelling only around the sting site    
  distant or more severe allergic reactions    
Infection History
Have infections been a problem?
no (Mark here, then skip to Birth History)
 yes
Infection history N/A ear infections sinusitis
  tonsillitis/strep throat pneumonia meningitis
  blood stream infections boils thrush
Antibiotic treatments per year 0-1 2-4 5-10
11-12 over 12    
Previous sinus CT scan normal abnormal none
Birth History - Adults Skip to Immunizations
Problems during pregnancy? yes
no
   
Premature or term (weeks) under 26
26-30
   
31-36
over 37
   
Lung disease at birth yes
no
 
If yes, required ventilation?
 yes
no
   
required oxygen?
 yes
no
   
Breast fed less than 4 months
4 months or more
   
Formula used cow's milk based soy based other
Immunizations
Routine childhood immunizations are up to date yes no I don't know
Received Pneumovax (pneumonia vaccine) or the Prevnar vaccine never within 1 year 2-5 years ago
over 5 years ago     I don't know
Tuberculosis status N/A negative test positive test
  treated for positive skin test or disease    
Flu shot received annually yes no    
Review of Systems (Current or within the last 12 months)
General no problems
failure to thrive
fevers
  chills
sweats
poor appetite
  fatigue
malaise
weight loss
Eyes no problems
blurring
double vision
  irritation
discharge
vision loss
  eye pain
light avoidance
itch
Ears no problems
earache
ear discharge
  ringing in the ears
vertigo
decreased hearing
Nasal no problems
nasal congestion
runny nose
  post nasal drip
deviated septum
nosebleeds
Throat no problems
sore throat
oral ulcers
  hoarseness
difficulty swallowing
 
Heart no problems
chest pains
heart disease
  palpitations
passing out
murmur
  difficulty breathing on exertion
difficulty breathing while lying flat
Respiratory no problems
cough
shortness of breath
  wheezing
chest tightness
chest pain
  difficulty breathing
recurrent bronchitis
coughing up blood
Gastrointestinal no problems
heartburn/GERD
difficulty swallowing
  nausea
vomiting
abdominal pain
  constipation
diarrhea
change in bowel habits
  jaundice
bloody stool
abdominal bloating
Urinary Tract no problems
pain on urination
blood in the urine
  discharge
urinary frequency
bed wetting
  urinary infections
urinary stones
 
Musculoskeletal no problems
back pain
bone pain
  joint pain
joint swelling
muscle cramps
  muscle weakness
stiffness
arthritis
Skin no problems
rash
suspicious lesions
  dryness
itching
sudden hair loss
Neurologic no problems
paralysis
weakness
  seizures
passing out
tremors
  dizziness
 
 
Psychiatric no problems
hyperactivity
behavior problems
  depression
anxiety
 
Metabolic no problems
cold intolerance
heat intolerance
  excessive drinking
excessive eating
unexplained weight loss
  excessive urination
 
unexplained weight gain
Blood/lymphatic no problems
abnormal bruising
bleeding
  enlarged lymph nodes
 
 
Medical Conditions
arthritis
glaucoma
kidney stones
cancer
heart disease
migraine headaches
diabetes
high blood pressure
osteoporosis
epilepsy/seizures
hepatitis
pneumonia
hiatal hernia/GERD
thyroid disease
ulcers
positive TB
HIV/AIDS
none
Personal Risk Factors
Smoking no use chew/dip cigarettes
  cigar smoker pipe smoker former smoker or use of tobacco products
Smoking (cigarettes) history N/A 1-5 years 6-10 years
11-20 years 21-30 years over 30 years
Alcohol no use less than 4 drinks per week    
4-7 drinks per week more than 7 drinks per week    
Drugs no use cocaine marijuana
  heroin speed other
Family History
Mother's history unknown allergies eczema recurrent infections
  no problems asthma other    
Father's history unknown allergies eczema recurrent infections
  no problems asthma other    
Brother's/sister's history unknown allergies eczema recurrent infections
  no problems asthma other    

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