HEALTH QUESTIONNAIRE. Do not take antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hours

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1 DaVita Medical Group - Allergy & Immunology 1625 Medical Center Point, Ste. # 100 Colorado Springs, CO (719) HEALTH QUESTIONNAIRE Do not take antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hours Patient s Name: Date of Birth: MRN: Date of Appointment: INSTRUCTIONS: Please answer the questions as they relate to the person being evaluated. A complete, accurate record is important in learning about your problems. Bring this completed form with you to your first appointment. Briefly describe your symptoms, the reason for your visit and what you hope to accomplish: PROBLEMS: Have you ever had any of the following conditions? Yes No Check all items Age Severity Comments What at medications help? onset Mild Mod Severe Asthma - wheezing Breathing problems shortness of breath/cough Sinus trouble Hay fever runny/stuffy/itchy nose/sneezing Hives/swelling Abdominal pain/heartburn/frequent burping Eczema/other rashes Recurrent/frequent infections sinus/ear Reaction to foods Reaction to drugs Reaction to insect stings Reaction to latex SYMPTOMS: Have you ever had any of the following? If not, leave blank. How many Severity days last Circle the most severe months Mild Mod Severe month? Runny/stuffy nose J F M A M J J A S O N D Itchy nose J F M A M J J A S O N D Sneezing J F M A M J J A S O N D Sinus pressure/headache J F M A M J J A S O N D Ears popping/fluid/pain/infection J F M A M J J A S O N D Eyes red/watery/itchy J F M A M J J A S O N D Wheezing J F M A M J J A S O N D Throat clearing/postnasal drip J F M A M J J A S O N D Coughing J F M A M J J A S O N D Wheezing/coughing w/ exercise J F M A M J J A S O N D Skin problems J F M A M J J A S O N D 2017 DaVita Inc. Page 1 of 5 #6463

2 Patient Name: 4. MEDICATIONS: List all medications you are taking now by name, dosage, and number of times per day. Include prescriptions, over the counter, oral medications, nasal sprays, eye drops, and all vitamins and supplements. Present medication for allergies Name of Medication Dosage Times per day Medications taken in the PAST for allergies Present medications for other reasons Drug allergies List drug and reaction 5. PREVIOUS ALLERGY EVALUATION AND THERAPY Have you ever had allergy skin tests? YES NO If YES when? Allergy blood test? YES NO If YES when? Physician: Please list the results of testing: (if possible, please provide copies) Have you ever received allergy injections? YES NO If YES when? 6. PRECIPITATING FACTORS (TRIGGERS) Check each symptom box which applies when you are exposed to the following: A. Environmental Dust exposure sweeping/vacuuming Molds mildewed areas/raking leaves Animal dander 4. Outdoor pollens grass/trees/weeds B. Weather/Environmental changes High winds Humidity Cold, dry air 4. Air conditioning/heating C. Respiratory infection/colds D. Physical exertion E. Irritants tobacco smoke/strong odors/cleaning chemicals F. Pollutants smog/motor fumes/sulfur dioxide/nitrous oxide G. Foods food additives/colorings/preservatives H. Emotional expressions laughter/crying I. Stress J. Hormone factors menses/other K. Medications Aspirin/NSAIDs Other L. Other triggers not listed Asthma Nose/Ears Eyes/Throat Headache Eczema Hives Other 2017 DaVita Inc. Page 2 of 5 #6463

3 Patient Name: 7. REVIEW OF SYMPTOMS: Circle each word which applies in each category. PART A: PERTINENT TO PRESENT PROBLEMS/EXTENDED CATEGORY General Health Excellent Good Fair Poor Full Body Fever Chills Fatigue Weakness Night sweats Head Headache Trauma Sinus pressure Eyes Itchy Pain Swelling Discharge Redness Cataracts Glaucoma Vision problems Pain Ears Infection Pain Hearing Problems Discharge Tinnitus Vertigo Ventilation tubes Myringotomy Obstruction Drainage Post nasal drip Bleeding Dryness Frequent colds Nose Good sense of smell Problems with smell Sinus infections Sneezing Itchy Polyps Snore Adenoidectomy Mouth Throat Skin Pulmonary Palate itching Change in taste Mouth sores Sore throats Throat clearing Post nasal drip Hoarseness Tonsillitis at age: Itching Dryness Hair/nail changes Rashes Hives Eczema Swelling Seborrhea Infections Chronic cough: Day Night Sputum (phlegm) Wheeze Shortness of breath Chest tightness Pain Hemoptysis Chronis/Recurrent Colds Sinuses Ears Bronchitis Pneumonia Diarrhea infections PART B: COMPLETE REVIEW OF SYSTEMS Recent weight loss Number of pounds over months or years Palpitations Shortness of breath Pain Swelling Cardiovascular Blood Pressure: HIGH LOW Arrhythmias Genital/Urinary Burning Pain Frequency Large amounts of urine Blood in urine Endocrine (hormonal) Thyroid Diabetes Cushings Blood Anemia Transfusions Lymph node enlargement HIV Testing: Bones/Joints/Muscles Pain Swelling Deformity Syncope Seizures/convulsions Gait problems Coordination problems Neurological Paralysis Weakness Speech problems Nausea Vomiting Diarrhea Constipation Gas Regurgitation Pain Gastrointestinal Colored stool: Black Tan Green Blood in stool Ulcers 8. PAST MEDICAL EVALUATIONS DIAGNOSES LAB WORK X-RAYS: Please provide any information available with type of test, when and where performed. Type of testing Date of testing Where was this testing done? 9. PAST MEDICAL HISTORY A. Please list other illnesses or chronic medical conditions you have had. Patient Name: 2017 DaVita Inc. Page 3 of 5 #6463

4 B. List all hospitalizations/surgeries: Please list most recent first with reason and date. 4. C. Immunizations: Did you experience any significant allergic reaction to any administered vaccine? If YES, please note what type of reaction to which vaccine in the space provided below. Are your immunizations up to date? YES NO Date of last Pneumovax: Date of last TETANUS: Date of last Shingles: Indicate here any reaction to vaccines you have experienced: 10. FAMILY HISTORY: Do any members of your family have allergies? If YES, list all relatives YES NO (parent/grandparent/sibling/children/etc.) Asthma Hay Fever Eczema Hives Frequent Pneumonia, sinus/ear infections Headaches Other allergies Medication allergies Hymenoptera Wasp/bees/ant/etc. Do any members of your family have any other illnesses? YES NO If YES, list all relatives as described above. Emphysema/other lung Cystic fibrosis Cardio-vascular disease Thyroid disease Glaucoma Diabetes Other 1 ENVIRONMENTAL SURVEY Where do you live? Age of your house? City Rural years months House construction: (brick, wood, etc.) Type of heating: Forced air Steam Space heater Baseboard Other: Type of air conditioning: Central Window Do you have an: a. Air purifier? Central Window unit b. Humidifier Central Window unit Are any rooms damp or musty? YES NO If yes, which ones? How many indoor plants do you have in the house? 2017 DaVita Inc. Page 4 of 5 #6463

5 Patient Name: Type of Carpet: Wool Synthetic Jute Other: Wall to Wall: YES NO Is entire house carpeted? YES NO Please list all rooms where carpeting is located: Do you have any stuffed furniture/soft upholstered/pillows? YES NO Which: Do you have any feather comforters YES NO Do you have any DOWN jackets/clothing? YES NO Is your mattress: Foam rubber Innerspring/cotton Cotton Waterbed Other: How old is your mattress? years months Is it encased in plastic? YES NO Do you have any pets? If YES, list number and kind (dog, cat, bird, horse, etc.): Do your pets spend time INDOORS? YES NO Are they allowed in the bedroom? YES NO 1 SOCIAL/OCCUPATIONAL HISTORY A. RESIDENCE: List your past residencies (city, state) with most recent first. City, State Urban or rural # of years Effect on symptoms (Better, worse, no change) B. OCCUPATIONAL HISTORY: List present occupation first, then past occupations. Brief job description How long? Effect of workplace on symptoms Are you exposed to anything at work that might aggravate your condition? If YES, what are they? Have you missed any work or school due to your allergies and/or asthma? If YES, how much time in the past 12 months? C. HOBBIES/RECREATIONAL ACTIVITIES: Please list any other exposures from these activities. 4. D. DO YOU TRAVEL FREQUENTLY? YES NO Are your symptoms better/worse at certain locations? Please describe. E. TOBACCO SMOKING HISTORY: Do you presently smoke? YES NO If YES, how many years have you been smoking? years Have you ever smoked? YES NO If YES, when did you stop? Average cigarettes per day at highest point: If you still smoke, do you think you could stop? YES NO Do any family members living with you now smoke? YES NO If yes, which ones? 2017 DaVita Inc. Page 5 of 5 #6463

6 DaVita Medical Group - Medical Center Point Exit 146 Garden of the Gods Rd. Austin Bluffs Pkwy. Austin Bluffs Pkwy. Exit 145 Templeton Gap Rd. Medical Ctr. Pt. Constitution *map not to scale 1625 Medical Center Point Located on the northwest corner of Fillmore & Union 2017 DaVita Inc.

Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs

HEALTH QUESTIONNAIRE Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs Patient s Name: Date of Birth: Date of Appointment: INSTRUCTIONS: Please