Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)

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1 Date: How did you hear about us? Patient Name: Internet Physician Referral Date of Birth: Friend Advertisement Patient Referring Physician: Primary Care Physician: _ Age: Reason for visit to allergy clinic: Allergy Symptoms: Symptoms: Seasonal? Yes Year round? Yes Duration: Severity: Triggers: ( Circle all that apply) Viral Infection, Tobacco Smoke, Leaf Smoke, Raking Leaves, Exposure to pets, Exposure to Grass, Exposure to Trees, Exposure to Weeds, Stress, Rainy Day, Cold Air, Hot Humid Day, Weather Change, Air Conditioner, Perfumes, Cosmetics, Hair Sprays, Chemicals, Paints, Exercise, Dust, Food, Drugs Absence from school or work? Night time Symptoms (Circle all that apply): Cough, Wheezing. Are the symptoms occurring more than 2 times a month? Or less than 2 times a month? Are symptoms exercise induced? Does exercise cause you to cough? Does exercise cause you to wheeze? Current Medications: Drug/Medication Allergies: Food Allergies: 1

2 Systemic Review: (Circle all that apply) General Weight: Gain/Loss Over how long? Tired all the time Easily fatigued Fever, Chills Easy Bruising or bleeding tendency Skin Rash (elbows, wrist, face, hands, feet, trunk, other) Hives, soap rash, contact rash Boils, infection, eczema Insect bite reaction (local, generalized) Dryness, itching Lumps under the skin Head Headache (above the eyes, all over Head injury Eyes Strain, change in vision Redness, puffiness, discharge Itching, rubbing Glasses, contact lenses Cataract, Glaucoma Ears Pain, discharge Itching, popping Infections, hearing loss Nose Frequent colds Sniffling, discharge (clear, discolored, thin, thick, constant, seasonal) Itching, rubbing, Sneezing Stuffiness, snoring (constant, seasonal) Bleeding Change in smell Endocrine Excessive sweating Excessive thirst Excessive hair growth Tendency to be too hot or too cold Swelling or lump in the neck Respiratory Wheeze, shortness of breath (with rest, with activity) Chest tightness Do colds settle in your chest? Cough (day, night, with exercise, with laughing, crying, wet, dry) Do you cough up blood? (Y, N) TB Test (normal or abnormal) Neurologic Dizziness, fainting, weakness Seizure Depression, anxiety Hallucination Cardiovascular Chest pain or pressure Murmur, palpitation High blood pressure High Cholesterol Musculoskeletal Weakness, leg cramps Joints, (pain, swelling, redness, stiffness) Osteoporosis Varicose veins or blood clots Gastrointestinal Appetite (poor, fair, good) Nausea, vomiting (occasional, frequent, with cough) Diarrhea, constipation, gas Pain, cramps Heartburn, acid reflux Excessive belching Stool (blood, mucous, worms) Trouble swallowing Throat Bleeding, sore, itch Clearing throat, hoarseness Bad breath, bad taste, change in taste Trouble swallowing Postnasal drip (clear, white, discolored) 2 Urinary Bloody or dark urine Poor control when coughing or sneezing Pain, itch Swelling, hernia Frequent urination

3 Past Medical History: (Circle all that apply) Cancer Diabetes Seizure Disorder Depression Anxiety ADD/ADHD Lung Disease Glaucoma Cataracts Hepatitis Migraine Headache Headaches Rash Past Hospitalizations: List most recent first Reason Date Past Surgical History: (Circle all that apply) Sinus Surgery Tonsils Adenoids Ear tubes Chest : Social History: Do you smoke? (Yes, No) Packs per day? How many years? Do you smoke inside? Do you smoke outside? If no, have you ever smoked? (Yes, No) Packs per day? How many years? How long ago did you quit smoking? (months, years) Exposure to second hand smoke? if yes, is exposure to second hand smoke inside or outside? Do you drink alcohol? (Yes, No) Do you use illegal drugs? (Confidential) (Yes, No) Job Title? Symptoms at work: Better/ same/ worse/ Place of employment Child: School or day care, how many days per week? Activities: Hobbies: Sports: Who lives with you? 3

4 Family History: Disease Father Mother Children Sibling Asthma Eczema Food Allergy Hay Fever Hives Drug Allergy Cystic Fibrosis Emphysema Arthritis Glaucoma Cancer Headaches, Migraine Heart Disease Diabetes Immunodeficiency Infant death Many infections Frequent miscarriages Seizure Stroke Thyroid Disease Tuberculosis 4

5 Immunizations: Childhood immunization completed (Yes, No) Please bring all immunization records Last flu shot Last pneumovax Severe reaction to immunization Previous allergy shots Date of last: Chest X-Ray Normal or Abnormal Sinus X-Ray Normal or Abnormal Sinus CT Scan Normal or Abnormal Women only: Are you pregnant or planning pregnancy? (Yes, No) Due date: Are you actively breastfeeding? (Yes, No) Allergy Survey: Living accommodations: (Circle all that apply) House, Apartment, Mobile Home, Town House, Age of building Location (city, suburb, country, on farm) Present address for years Basement, finished, carpet, damp, dry, dirt Recent painting or repair (yes) (no) Water Damage, (Yes, No) Repair? Date repaired Heating system: Forced air, space heat, hot water, wood burn, Natural Gas, Propane, Electric, Oil Flooring Wood, carpet (wool, synthetic, other), tile, vinyl Moist, Damp, Very damp Window treatment (blinds, shades, drapes) Air conditioning: central, window unit Humidifier, Dehumidifier Bedroom: Mattress (regular, rubber, waterbed futon) Dust Mite Encasement on mattress and box spring (Yes, No) Box Spring Cover (cotton, allergy proof) Pillows (polyester, feather, foam other ) Dust mite encasement on pillows (Yes, No) Floor: Carpet, Wood, Vinyl, Tile) items in bedroom (upholstered furniture, Stuffed Animals) Pets: (How many) Cat(s), Dog(s), Horse(s), Are pets indoors or outdoors? Horse Sleep in bedroom or on bed? (Yes, No) Yes, how often? (Frequently, Sometimes) Rodent, Birds Allergic to Latex? Yes/No Sting Insects: Reaction to insect stings? (Local, hives, wheezing, passing out) 5

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