NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician:

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1 Patient s Name: NEW PATIENT HISTORY Last First Middle Age: Primary Care or Referring Physician: Name How do you hear about our office? Referred by physician: (name): Referred by family or friend Facebook Address Advertisement Internet Other: Please check Yes or No: Symptoms Eye Symptoms Cough? Itching? Wheeze? Watering? Tight Chest? Redness? Fatigue? Puffiness? Shortness of breath Nasal Symptoms Ear Symptoms Nasal Drainage? Itching? Sneezing? Infections? Stuffy nose? Mouth Breathing? Skin Symptoms Itch of the roof of your mouth? Hives? Snoring? Rashes? Sinus Headache? Eczema? Have you had sinus infections? If yes, how often? Do symptoms awaken you at night? If yes, which symptoms and how often? Are you limited in your daily activities? Do you miss days of work/school because of your illness? How many in the last year? Have you gone to the emergency room because of asthma/allergy episodes? frontdesk@allergyandasthmaconsultants.com Page 1 of 6

2 ALLERGY/ASTHMA TRIGGERS Which of the following trigger your symptoms? Certain times of the year? If yes, which times? Open windows? Animals If yes, which ones? Cutting grass? Food? If yes, which ones? House dust/vacuuming? Damp, musty areas? Cold air? Exercise? Irritants? (Perfumes, aerosol sprays, etc.) Are you allergic or sensitive to any medications? Have you ever had a life threatening reaction to: Foods: Insect stings (bee, wasp): Rubber/latex: MEDICAL/ALLERGY TESTING Have you ever had? Chest X-Ray? If yes, date of most recent X-Ray: Sinus X-Ray or CAT Scan of sinuses? If yes, date? Allergy Testing? If yes, date of most recent test: Have you ever taken allergy shots? If yes, how long? When? Pulmonary Function Testing? If yes, date of most recent test: frontdesk@allergyandasthmaconsultants.com Page 2 of 6

3 List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often? List your other medications, including over-the-counter medications: Medication Dose How Often? Have you ever taken prednisone, cortisone or other steroids (by mouth)? Are you allergic or sensitive to any medications? If yes, which ones? FAMILY HISTORY Do other family members have asthma, sinus problems, or frequent infections? If yes, who? PREGNANCY Are you currently pregnant? Not applicable if male, postmenopausal, or child Are you planning a pregnancy? SMOKING Do you currently smoke? Have you smoked in the past? If yes, for how many years? How much a day? When did you quit? Does anyone in your home smoke? Do you drink alcoholic beverages? If yes, for how many drinks per day? frontdesk@allergyandasthmaconsultants.com Page 3 of 6

4 TYPE OF HOME Single family dwelling Apartment Condo Mobile home Age of home: Is there a basement? If yes, is it? Always dry Rarely leaky Frequently leaky Does your basement smell damp or musty? If no basement, is there a? Concrete slab Crawlspace If yes, which ones? HEAT/AC Air Conditioning? Window Unit Central Heat? Gas Electrical Radiant Wood Humidifier on furnace? Do you use a fireplace or wood-burning stove? If yes, how often? Do you open windows in mild weather? Do you have an attic fan? BEDROOM Location of bedroom? Basement Ground floor Second floor or above Floor cover in bedroom? Carpet Tile Hardwood Linoleum Other: If carpet, how old? months years Composition, if know: Stuffed animals in bedroom? If yes, how many? If yes, how many? Mattress Waterbed Conventional/Fiber-Filled Fiber Content: Age: months years Pillows Fiber Content: Polyester-filled Feather/down Foam rubber Age: months years Do you have a down comforter? ANIMAL/PETS Do you have any? If yes, kind(s) indoor? If yes, kind(s) outdoor? How long have you had the animal(s)? HOUSE PLANTS Do you have any? If yes, how many and type? frontdesk@allergyandasthmaconsultants.com Page 4 of 6

5 MEDICAL HISTORY Have you ever had? Bronchitis? Blood disease? Pneumonia? Anemia? Emphysema? Osteoporosis? Exposure to tuberculosis? Bone fractures? Positive TB skin test? Stomach problems? Other lung disease? Ulcers? Heart Problems? Hernias? Heart Attack? Eye problems? High blood pressure? Cataracts? High Cholesterol? Glaucoma? Diabetes? Seizures? Kidney disease? Have you ever needed oxygen? Liver disease? Have you ever stopped breathing? Cancer? Have you ever been hospitalized? If yes, give reasons and dates: Reasons for hospitalization Dates Have you ever had surgery? If so, give reasons/procedures, dates: Reasons Procedure/s Dates Page 5 of 6

6 Do you currently have: REVIEW OF SYSTEMS Constitutional Hematology/Lymph Musculoskeletal Fatigue Loss of appetite Joint pain/stiffness/swelling Fever Swollen glands Sciatica ENT Psychology Cardiology Loss of Smell Anxiety Chest Pain Hearing Loss Depression Dizziness Ringing in Ears Sleep disturbances Palpitations Gastroenterology Ophthalmology Endocrinology Abdominal pain Blurring of Vision Cold/Heat intolerance Difficulty swallowing Diminished Vision Excessive thirst Heartburn Vision Loss Increased urination Nausea/Vomiting Difficulty urinating Endocrinology Dermatology Urology Neurology Hives Difficulty urinating Memory Loss Rash Frequent urination at night Seizures Dry or sensitive skin PEDIATRIC PATIENTS ONLY Length of pregnancy? months Were there problems during pregnancy, delivery, or newborn period? If yes, please explain: Birth weight? lbs. oz. Has your child had chicken pox? Has your child had RSV? Are your child s immunizations up to date? RESEARCH STUDIES Dr. Onder and Allergy and Asthma Consultants, P.C. conduct clinical research studies on new allergy and asthma medications. Would you be interested in you or your child participating in studies of new medications? Maybe frontdesk@allergyandasthmaconsultants.com Page 6 of 6

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