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1 1 first name middle initial: date of birth / / please answer all questions to the best of your knowledge. completion of this intake information is an essential part of your medical care. current medication name of medications route (i.e., by mouth, inhalation, injection) dosage frequency (i.e. once/ twice a day, as needed) length of time taking this medication prescribed medications over the counter medications herbal medications
2 2 MEDICAL HISTORY 1) check all conditions below with which you have been diagnosed: bronchitits bronchiolitis pneumonia sinus infection skin infection/abscess chronic diarrhea how long have you experienced this condition?: infection of bone infection of blood meningitis _ 2) have you had blood transfusion in the past?: yes no reasons for tranfusion 3) please check all medical conditions that apply to you: migraines glaucoma heart disease high blood pressure diabetes thyroid disease, low thyroid disease, high high cholesterol hepatitis a, b, or c tuberculosis sleep apnea osteoporosis rheumatoid arthritis sle/lupus autoimmune disease heart disease, please specify: neurological disorder, please specify: cancer, please specify: other conditions: 4) history of exposure to chicken pox: never had chicken pox vaccinated have had chicken pox 5) flu shot: receive flu shot yearly never received flu shot some years but not every year; last flu shot received was on
3 3 ALLERGY HISTORY: 1) have you had reactions to the following?: medications name of medication: others: name of medication: others: name of medication: others: foods type of food: others: foods type of food: others:
4 4 foods type of food: others: insect stings type of insect: swelling at the sting site others: latex product type of product: others: radio-contrast media (iodine/dye) name of the contrast media: others:
5 5 anesthetic agents name of medication: nausea vomiting diarrhea others: SURGICAL HISTORY please check all of your past surgeries: month/year of surgeries reasons adenoidectomy / appendectomy / back surgery / c-section / gall bladder removal / sinus surgery / tonsillectomy / tubal ligation / vasectomy / pe tubes / other, please specify / HOSPITALIZATION please describe all of your past hospitalization(s): month/year of hospitalization reasons staying overnight in a hospital / / / emergency room visits / / /
6 6 FAMILY HISTORY mother father siblings child maternal maternal maternal maternal paternal paternal paternal paternal cousins grand grand aunts uncles grand grand aunts uncles mother father mother father alcoholism/drug allergy seasonal/ year round allergy, anesthetic agent allergy, drug allergy, food allergy, insect sting allergy, latex arthritis asthma autoimmune disease birth defect blood disorder cancer cystic fibrosis diabetes eczema emphysema hay fever heart disease high blood pressure high cholesterol immuno-deficiency kidney disease liver/intestinal mental illness mental retardation migraines seizure disorder thyroid disorder tuberculosis other:(disease name)
7 7 SOCIAL HISTORY 1) smoking: never yes average pack per day of cigarettes: year started with smoking: year stopped smoking: determination to quit 2) recreational drug use: no yes 3) exercise 2-3 times per week on a regular basis: yes no 4) alcohol: no socially become intoxicated with alcohol never 2-3 times per year fewer than 6 times per year 6-10 times per year once a month or more 5) marital status: single married divorced separated widow/widower 6) employment status: full time part time unemployed IMMUNOTHERAPY HISTORY 1) have you received allergy shots in the past? no yes a) year that you first started on allergy shots: b) last time you received allergy shots: month: year: c) have you had systemic reactions (i.e., full body hives, difficulty in breathing, including wheezing, ) to allergy shots? no yes ENVIRONMENT HISTORY 1) type of your current residence: house apartment mobile home condominium 2) age of your current residence: years old 3) location of your residence: urban rural farm 4) how long have you lived in this residence? years 5) how long have you lived in colorado? years 6) other state(s)/country where you have lived: continued on next page
8 8 ENVIRONMENT HISTORY continued 7) the following questions pertain to detailed description of your residence: please check all that apply: a) basement: no basement crawl space completely finished partially finished unfinished basement flooring: carpeting hard surface both water damage: never water damage has been fixed current water damage has not been fixed b) possible mold exposure: none leaky roof visible moldy spots musty smell water damage that has been fixed professionally currently has water damage that has not been fixed c) hot tub: none outdoor indoor d) cooling system: air conditioner none swamp cooler e) heating system: gas electric hot water wood burning stove f) fireplace: none type of fireplace: gas wood frequency of use: never used fewer than three times per year more than three times per year used as a heat source g) humidifier: none type of humidifier: central portable frequency of use: never throughout the year throughout winter season only when a family member develops a cold other: h) air purification system: central hepa filter portable hepa filter none electronic filter ionic breeze other: i) flooring in your house: hard surface in the entire house carpeting throughout the house except kitchen and bathrooms carpeting in bedrooms only carpeting in bedrooms and living areas only other:
9 9 ENVIRONMENT HISTORY continued j) patient s bedroom: location of bedroom: main floor 1st floor 2nd floor basement flooring of bedroom: hard surface carpet age of mattress: < 5 years 5-10 years > 10 years age of pillows: < 5 years 5-10 years > 10 years allergen-proof covers: not used used for pillows used for mattress used for comforters box spring down bedding: none pillows comforter cleaning of pillowcase and sheet: once a week twice a month once a month < once a month use warm water use hot water cleaning of comforter: once a week twice a month once a month < once a month use warm water use hot water k) pets: none type of pets: dog(s) number of pet dog(s): cat(s) number of pet cat(s): rabbit(s) number of pet rabbit(s): guinea pig(s) number of guinea pig(s): hamster(s) number of hamster(s): bird(s) number of pet bird(s): other: number of pet animal(s): pets are kept: exclusively outdoors in the lower level and not allowed upstairs in the house but not allowed in patient s bedroom in the house and allowed in patient s bedroom l) exposure to cigarette smoke: none yes smokers: self spouse child(ren) parent(s) relatives co-workers places where exposure occurs: in the house in the car at work 8) please describe your occupational history: years start to finish job title job description 9) please list your hobbies:
10 10 REVIEW OF SYSTEM please check all symptoms that you have experienced and/or are currently experiencing. constitutional weight loss weight gain loss of appetite fever night sweat fatigue difficulty falling asleep restless sleep headaches upon awakening on a regular basis excessive drowsiness during the daytime dermatology sleep disturbances rash eczema dry or sensitive skin hives photosensitivity acne hair loss birthmarks nail abnormalities changes in color or size of moles allergy stuffy nose runny nose sneezing itchy watery eyes skin reaction to metals skin reaction to cosmetics skin reaction to chemical food allergy insect sting allergy latex allergy ear, nose & throat reaction to anesthetic agents hearing loss ringing in the ears ear pain dizziness nose bleed loss of taste or smell sensation facial pain stuffy nose runny nose sore throat snoring post nasal drip thrush bad breath hoarseness of voice ulcer in the mouth opthalmology mouth breathing itchy watery eyes seasonal eye symptoms eye irritation drainage from eyes diminished vision loss of vision double of vision respiratory blurring of vision wheeze chest tightness up blood chest pain noisy breathing exposure to tuberculosis symptoms nighttime exercise-induced more than 2 weeks with a cold cardiology chest pain heart murmur irregular heart beat racing heart beat leg swelling dizziness fainting varicose vein continued on next page
11 11 REVIEW OF SYSTEM continued gastroenterology difficulty swallowing nausea vomiting heartburn bloating abdominal pain constipation diarrhea change in bowel habits blood in stool urology/reproductive pregnant nursing recurrent kidney or bladder infection frequent urination at night unable to hold urine urinary urgency difficulty in urination abnormal urine stream blood in urine pain with urination female reproductive system abnormal periods cramps lasting longer than first few days of periods pain with sexual intercourse abnormal vaginal discharge hot flashes infertility male reproductive system infertility abnormalities of erection/ejaculation endocrinology cold intolerance heat intolerance excessive appetite excessive thirst frequent urination at night abnormal development of facial/body hair musculoskeletal joint stiffness joint pain joint swelling back pain Osteoporosis muscle weakness or pain neurology headaches migraines memory loss dizziness double vision seizures stroke numbness abnormal balance muscle weakness psychology depression mood swings concentration problems anxious high stress level sleep disturbances eating disorder mental or physical abuse suicidel ideations hematology swollen glands easy bruising difficult to stop bleeding anemia varicose veins other:
child s last name: first name middle iditial: date of birth / /
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