ALLERGY & ASTHMA SPECIALISTS, P.C.

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ALLERGY & ASTHMA SPECIALISTS, P.C. Leonard Silverstein, M.D. Ruth L.K. Gold, M.D. Health Questionnaire Jennifer A. Sherman, D.O. Niya Wanich, M.D Patient: D.O.B.: / / Age: Date: / / Height: Weight: Reason for visit: Medications: Drug Name Dose Frequency (e.g. 10 mg.) Please list the name, dosage and frequency of the medications you are currently taking. (For example, Digoxin 0.125 mg, two tablets daily.) Drug Allergies: Drug Reaction Please list any drug allergies, including reactions. Please state NONE if no allergies. Allergy/Asthma Medications: Please list the name of any allergy/ asthma medications you have tried and whether they have helped you. Name Helped? Y/N Local Pharmacy: Address: Phone #: Mail Order Pharmacy: Phone #: 82 East Allendale Road, Suite7, Saddle River NJ 07458 Tel(201)236-8282 Fax(201)236-0138 51 Route 23 South, Riverdale, NJ 07457 Tel(973)831-5799 Fax(973)831-7422 www.njallergydoctors.com

PLEASE SELECT ALL MEDICAL CONDITIONS FOR THE PAST SIX MONTHS: No Prior Serious Illness Asthma Emphysema High Blood Cholesterol Premature Birth Broken Nose Food Allergy Hives Resp. Support at Birth Bronchitis Frequent Headaches Hormonal Difficulty Seasonal Allergies Croup Hay Fever Migraine Sinus Disease Deviate Septum Heart Disease Nasal Polyps Skin Drug Allergy High Blood Pressure Nasal Surgery Stomach Disease Eczema Overactive Thyroid Underactive Thyroid Cancer: Please describe type of cancer and treatment you have received. (For Example, radiation, chemotherapy, surgery) Other: PLEASE SELECT ALL FAMILY MEDICAL CONDITIONS: Family History Mother Father Sister Brother No Significant Family History Asthma Seasonal Allergies Hypertension Stroke Drug Allergy Cancer Kidney Disease Eczema Diabetes Food Allergy Heart Disease Osteoporosis Frequent Headaches High Cholesterol Respiratory Problems Other

Surgical History Adenoidectomy PE Tubes Sinus Surgery Septoplasty Tonsillectomy with Adenoidectomy No Significant Surgery Other Social History Use of Alcohol: None Social Moderate Heavy Smoke Exposure Secondhand Smoke: Yes No Patient Smoke: Yes No Frequency: Current every day smoker Current some days smoker Former smoker Never smoked Smoker, current status unknown Cigs/day years Pets In The Home None Dog(s) Cat(s) Bird(s) Rabbit(s) Rodent(s) Horse(s) # # # # # # Pet(s) allowed in the patient s bedroom? Yes No Housing Dwelling City Suburbs Rural House Apartment Condo How long has the patient lived at this residence? Months OR Years Age of Building: Bedding (What type of bedding does the patient use): Pillow type: Synthetic Feather/Down Does this patient use a down comforter? Yes No Does this patient use allergy coverings? Yes No Floor Covering Bedroom: Area Rugs Ceramic Tile Wall to Wall Wood House: Area Rugs Ceramic Tile Wall to Wall Wood HVAC Air Conditioning: Central Wall None Heating: Forced Air Radiant/ Baseboard Stove Unknown

Basement None Unfinished Finished Is there chronic leakage? Yes No Employment/School Occupation: Location: Patient works inside Patient works outside Patient is: Student Unemployed Retired Employment/ School Chemicals Molds Young Children Exposure: Symptom Status while at Better Worse Same work/school: School: Daycare Pre-school Full-time student Part-time student REVIEW OF SYMPTOMS: (Please put CHECK MARK if patient has had any of these symptoms.) Constitution Eyes/Head ENT Respiratory Decreased Appetite Vision Changes Nasal Congestion Chest Tightness Chills Shiners Nasal Discharge Cough Failure to thrive Itchy, Watery, Red Nose Bleeds Difficulty Exercising Fatigue Tension Headaches Ear Pain Shortness of Breath Fever Sinus Headache Post Nasal Drip Sputum Production Night Sweats Migraine Headache Sneezing Wheezing Sleep Problems Dizziness Snoring Weight Change Sore Throat Tinnitus (ringing in ears) Cardiovascular Gastrointestinal Hematology Endocrine Edema (Swelling) Abdominal Pain Anemia Cold Intolerance Murmurs Constipation Bleeding Heat Intolerance Palpitations Diarrhea Bruise Easily Fainting Reflux (Heartburn) Swollen Glands Chest Pain Nausea Vomiting Musculoskeletal Skin Psychiatry Joint Pain Acne Anxiety Back Pain Alopecia Depression Muscle Pain Contact Dermatitis Developmental Delays Osteoporosis Eczema Hyperactive Stiffness Hemangioma Irritable Hives/Swelling Mood Swings Rash/Itching Stress Warts

PLEASE COMPLETE THIS SECTION FOR CHILDREN UNDER THE AGE OF 18 Birth Weight lbs. ozs. Vaginal Delivery C-Section Premature:? Weeks Complications: Are immunizations up-to-date? Feeding: Formula Only Breast Fed How Long? Transition from breast milk with no problems? Problems transitioning from breast milk? Yes No

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