Medical History Form
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1 Dr. Vivek U. Rao, M.D. 500 Adams Ave., Suite 300 Odessa, TX Phone: Fax: Medical History Form Patient Name: DOB: A. CHIEF COMPLAINT: Briefly describe your (or your child s) most bothersome symptom (i.e. runny nose, cough, etc.): B. DRUG ALLERGIES/ADVERSE REACTIONS: 1. Have you ever had a reaction to any of the following? Penicillin Aspirin Radiocontrast dye Latex Other medication: If so, please give details: None of the above C. USE OF BLOOD PRODUCTS: 1. Do you have any objections (religious or otherwise) to blood transfusions or the use of blood-derived products? Yes If yes, please explain: D. CURRENT MEDICATIONS: Please list all medications taken in the past month. Please include over-the-counter medications and herbals/supplements. If you need more space, please use the back of this form. Name Strength Frequency Reason for medication Prescribing Physician Date Started Date Stopped Example: Zyrtec 10 mg 1 tablet nightly Allergies Dr. John Doe 12/5/2006 1/1/2007 Example: Flonase 2 sprays/ nostril daily Allergies Dr. John Doe 6/1/2004 1/4/2007 1
2 E. PAST MEDICAL HISTORY: 1. Have you ever been diagnosed with any of the following? Acid reflux disease Anxiety Arthritis Asthma Cancer COPD Depression Diabetes Heart disease High blood pressure High cholesterol Pneumonia Seizures Thyroid disease Other: 2. Please list all surgical procedures (including tonsillectomy and ear tubes) and prior hospitalizations (please give dates): _ F. IMMUNIZATIONS: 1. Date of last flu shot: 2. Date of last pneumonia vaccine: G. FAMILY HISTORY: 1. Please indicate if any family members have the following (please include relationship i.e. mother, son): Asthma Hives/angioedema Hay fever Nasal polyps Eczema Cystic fibrosis Food allergies Sinus disease Drug allergies Aspirin sensitivity Immune Deficiency Autoimmune disease (lupus, etc.) Childhood deaths (please give details) 2. Family member Alive? Age (if still alive) Medical problems not listed above Mother: Y / N Father: Y / N 3. Number of brothers: Number of brothers still alive: Medical problems: 4. Number of sisters: Number of sisters still alive: Medical problems: 5. Number of sons: Number of sons still alive: Medical problems: 6. Number of daughters: Number of daughters still alive: Medical problems: 7. If there is other information regarding your family history that you feel we should know, please give details here: H. SOCIAL HISTORY: 1. Have you ever smoked? Yes 2. If yes, how many years total did you smoke? 3. How many packs per day did you smoke on average during this period? 4. If you have stopped smoking, how long ago did you stop? years months 5. Does anyone else at home smoke? Yes If yes, please give details: 6. Do you drink alcohol? Yes If yes, please indicate number of drinks per week: 7. Have you ever used illegal drugs? Yes 2
3 8. What is your occupation? Student (please give school and grade/year of study) Homemaker Retired (if retired, please give former occupation): Other: 9. Did you ever work in an occupation or have any hobbies in which you were exposed to dusts, mists, fumes, chemicals, or radiation? Yes If yes, please give details: I. NASAL/EYE SYMPTOMS: 1. Do you have any nasal or eye symptoms? Yes 2. If yes, how long ago did symptoms begin? 3. What symptoms do you experience? Runny nose Postnasal drip Stuffy nose Itchy nose Sneezing se bleeds Itchy eyes Red eyes Gritty feeling in eyes 4. Do you have at least some nasal or eye symptoms year-round? Yes 5. Which seasons are the worst? Spring Summer Fall Winter 6. When are symptoms the worst? Early morning During or after meals Night Symptoms are the same regardless of time of day 7. Which of the following seem to make symptoms worse? Cats Dogs Dust Pollens Molds Fumes Smoke Perfumes Strong odors Other: 8. Have you ever used nasal sprays? Yes Prescription: Over-the-counter (Afrin, etc.): Salt water sprays (Ocean Spray, etc.): 9. Have you ever used eye drops? Yes Prescription: Over-the-counter (Visine, etc.): J. CHEST SYMPTOMS: 1. Have you ever had any chest symptoms? Yes If no, skip to Part K 2. What symptoms have you experienced? Wheezing Chest tightness Shortness of breath Cough Other: 3. How long ago did symptoms first begin? 4. Do you have heartburn? Yes If yes, how often? 5. Do you ever have hot or sour material in the back of your throat when you bend down or lie down? Yes 6. How many times have you been hospitalized for chest symptoms: In your whole life: In the last 12 months: 7. Have you ever been intubated (breathing tube placed into your windpipe and machine used to help you breath)? 3
4 8. How many times have you gone to the Emergency Room for chest symptoms: In your whole life: In the last 12 months: 9. In the past 12 months, how many days of school/work have you missed because of chest symptoms? 10. Are your activities restricted because of chest symptoms? Yes (please explain): 11. Do chest symptoms interfere with sleep? Yes If yes: How many nights a month? Please describe symptoms at night: 12. Which of the following seem to make your chest symptoms worse? Air conditioning Cold air Colds/other infections Temperature changes Dampness Exercise Cats Dogs Other animals Dust Pollens Molds Fabrics Fumes Smoke Insecticides Perfumes Strong odors Menstrual periods Stress Other: 13. Which seasons are the worst? Spring Summer Fall Winter 14. When are symptoms the worst? Early morning During the afternoon Night Symptoms are the same regardless of time of day 15. Have you ever taken medications for your chest symptoms? Yes Inhalers: Pills: Liquids: Nebulizer: 16. Have you ever had steroid injections, steroid pills, or steroid liquids (Prednisone, Medrol, Pediapred, etc.) for chest symptoms? Yes If yes: How many different times: Please list name, dose, and number of days the steroid was taken: 17. Do you currently use a peak flow meter? Yes 18. If yes, what are your usual readings In the morning? In the evening? K. SKIN: 1. Do you have skin problems (hives, swelling, rash, eczema, or itching)? Yes If no, skip to Part L 2. Describe your skin problem: 3. When did the problem first begin? 4. Have you ever had significant swelling of body parts (eyelids, lips, etc.)? Yes (please explain): L. FOODS: 1. Have you ever had a reaction to foods or beverages (itching of the mouth, rash, swelling, etc.)? Yes If no, skip to Part M 2. Please explain the nature of your reaction(s): 4
5 M. MISCELLANEOUS: 1. Have you ever had a reaction to stinging insects (bees, wasps, ants, etc.)? Yes If yes, please describe the reaction: Swelling that occurred only at the location of the sting Hives Other (please describe, and please give date of reaction): 2. Is this your first time to see an allergist? Yes If no, please give name of allergist and dates seen: 3. Have you had allergy testing before? Yes If yes, please give date and results: 4. Have you been on allergy shots in the past? Yes If yes, please give start/stop dates and allergens present in the shots: N. LIVING ACCOMMODATIONS: 1. What type of building do you live in? House Apartment Other: 2. What year was the building built? (If not sure, give estimate.) 3. Where is it located? City Country Farm 4. How long have you been at this address? 5. Recent painting or repair? Yes If yes, please describe and give dates: 6. Type of flooring in your bedroom: Hardwood Carpet Other: 7. Pillow in bedroom: Feather Synthetic Foam 8. Is the pillow covered with an anti-allergy cover? Yes 9. Do you use a down comforter in the bedroom? Yes 10. Type of mattress: Innerspring mattress Waterbed 11. Is the mattress covered with an anti-allergy cover? Yes 12. Bedroom has: Humidifier Dehumidifier 13. Type of flooring in rest of the building: Hardwood Carpet Other: 14. Window treatment: Blinds Shades Drapes 15. Age of window treatment: 16. Type of air filter in building: Fiberglass Electrostatic HEPA Other 17. Do you have pets? Yes a. If yes, indicate type and number of each: Cat Dog Bird Gerbil Other: b. Do the pets ever come into the house? Yes c. Do the pets ever go into your bedroom? Yes 18. Which of the following pests have been a problem in your home in the past year? Cockroaches Mice Rats ne of these 5
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Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST
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Patient s Name Date of Appointment Date of Birth Referring Physician 1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.
(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most?
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