Date of Birth Sex: M or F Age

MEDICAL HISTORY FORM For Office Use Only Pt# HT WT BP HR RR 500 South University Suite 215 Little Rock, AR 72205 Phone 501-420-1085 Fax 501-420-1457 Patient Name: Last First Middle Initial Date of Birth Sex: M or F Age How did you hear about our clinic? (Circle all that apply) Physician (Name: ) Family/friend (Name: ) Internet /Website Yellow Pages Facebook Google Insurance Directory Television Magazine/Newspaper Ad List other family members seen by Dr. Graham: Referring Physician: Primary Care Physician: Other relevant Physicians: CHIEF COMPLAINT What is the MAIN reason for your visit? How long have you had this problem? NASAL/HEAD SYMPTOMS (Circle all that apply) N/A itchy eyes sinus infections loss of smell nasal polyps watery eyes posterior nasal drip sore throat throat clearing dry eyes ear pressure itching of throat sneezing dark circles under eyes dizziness hoarseness itchy nose headache sinus pressure nasal congestion snoring frequent ear infections runny nose loss of taste cough sleep apnea nose bleeds roof of mouth itching At what age did you first experience these symptoms? When do you experience these symptoms? (Circle all that applies) Year round Spring Summer Fall Winter Do these symptoms interfere with daily life? Yes or No 1

NASAL SYMPTOMS CONTINUED Severity of symptoms (Circle all that apply) Mild Moderate Severe Worsening Stable What are the TRIGGERS? (Circle all that apply) No Known Triggers Allergens Irritants Weather Changes cut grass perfumes cold fronts dead grass smoke temperature changes dead leaves paint warm weather dust hair spray damp weather hay outside dust windy days feathers tobacco smoke humidity mold or mildew strong scents time of day tree pollen lying down others not listed weed pollen while eating dogs cats other animals Have you had previous allergy testing? Yes or No If yes, what physician evaluated you? Results: Skin testing Year N/A Results: Blood testing Year N/A Have you ever had allergy injections? Yes or No If so, how many years? What physician prescribed the injections? Did your symptoms improve while on allergy shots? Yes or No Have your symptoms worsened since discontinuing injections? Yes or No RECURRENT INFECTIONS N/A Number of ear infections past 12 months lifetime PE tubes: Yes or No # of sets Number of sinus infections past 12 months lifetime Number of pneumonias past 12 months lifetime Number of antibiotics in the last year Names of antibiotics taken Number of hospitalizations for infections Reasons: Have you had a previous immune workup? Yes Date No_ Have you had a previous ENT consultation? Yes Date No Name of ENT Dr. Date of last visit: Have you had a sinus x- ray? Yes Date No Have you had a sinus CT? Yes Date No HEADACHE SYMPTOMS N/A How long have you had headaches? How often do you get headaches? daily >2 times per week <2 times per week How long do they last? What do you do to relieve your symptoms? Location? Temple area Forehead Top of head Back of head Do you have any nausea or vomiting associated with your headaches? Yes or No Are you sensitive to light or sound? Yes or No 2

CHEST SYMPTOMS N/A What are your MAIN chest symptoms? (Circle all that apply) asthma cough shortness of breath chest tightness wheezing chest congestion recurrent chest infections At what age did you first experience these symptoms? Are symptoms getting worse? Yes or No How would you describe your symptoms? (Circle all that apply) mild moderate severe uncontrollable stable worsening Triggers (Circle all that apply) colds or infections exercise/exertion cold air laughing dust morning time night time perfumes/strong odors cats hot or humid weather when lying down stress/anxiety Are your symptoms worsened with seasons? (Circle all that apply) spring fall summer winter year round Has recurrent bronchitis been a problem? Yes or No Recurrent pneumonia? Yes or No Was the first episode of wheezing with RSV or bronchitis? Yes or No Days of work or school missed in the past year? ER visits # in the past year # in lifetime Hospitalizations # in the past year # in lifetime Intubation? Yes or No Intensive care admissions? # in the past year # in lifetime Oral steroids # in the past year # in lifetime Steroid shots # in the past year # in lifetime Date of last chest x- ray TREATMENTS Previous treatments tried but failed: Have you seen a Pulmonologist? Yes or No If yes, name of physician Date last seen Answer the following questions to evaluate your chest symptoms over the PAST 4 WEEKS and write the number of each answer in the score box provided. Then add up the score boxes to get the TOTAL. 1. How much of the time did your chest symptoms keep you from getting as much done at work, school or at home? All of the time 1 Most of the time 2 Some of the time 3 A little of the time 4 None of the time 5 2. How often have you had shortness of breath? More than once a day 1 Once a day 2 3 to 6 times a week 3 Once or twice a week 4 Not at all 5 3. How often did your chest symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? 4 or more nights a week 1 2-3 nights a week 2 Once a week 3 Once or twice 4 Not at all 5 4. How often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 3 or more times per day 1 1-2 times per day 2 2-3 times per week 3 Once a week or less 4 Not at all 5 5. How would you rate your asthma control? Not controlled at all 1 Poorly controlled 2 Somewhat controlled 3 Well controlled 4 Completely controlled 5 TOTAL 3

REFLUX SYMPTOMS N/A Do you suffer from heartburn or indigestion? Yes or No Do you have a history of reflux? Yes or No If yes, are you taking medication to treat it? Yes or No What medications are you taking? Do you have difficulty swallowing? Has food gotten stuck when swallowing? Yes or No Have you seen a Gastroenterologist? Yes or No Physician Name Last EGD: ECZEMA (dry, flaky sensitive skin) N/A When did it start? Infancy Childhood As an adult Severity? Mild Moderate Severe Uncontrollable Triggers? Do foods make it worse? Yes or No If yes, list foods: Treatments used: If prescription medications, creams, and/or ointments, please list the strength: FOOD REACTIONS N/A Suspected food(s)? Age when first reaction occurred How many reactions have occurred? Symptoms of reactions How long from time of ingestion? Describe the reaction Treatment: ER visits?: Were you given an Epi- pen or Auvi- Q? Yes or No Have you used the Epi- Pen or Auvi- Q? Yes or No HIVES AND SWELLING SYMPTOMS N/A Do you have hive symptoms? Yes or No How long have you had hives? days weeks months years When do the hives usually occur? early morning immediately after eating evening random middle of the night How long are your hives present? less than an hour several hours >24 hours Triggers: (Circle all that apply) heat cold exercise foods medications pressure unknown Where do they occur on the body? (Circle all that apply) face scalp extremities trunk entire body Have you ever had swelling of the following: (Circle all that apply) lips tongue face throat hands extremities other Do you have any of these symptoms at the time of your hives? (Circle all that apply) swelling wheezing fainting dizziness throat swelling vomiting diarrhea fever nausea joint symptoms bruising Have you been to the ER or hospitalized in the past year because of hives or swelling? Yes or No If yes, please explain: Have you taken oral steroids in the past year for hives or swelling? Yes or No Has a physician ordered any blood tests? Yes or No If so, what Dr. When were these tests ordered? 4

RASH N/A Describe the appearance: (Circle all that apply) red, rough patches itchy raised welts red bumps Location? How long has it been present? Is it worsening? Yes or No Are there any known triggers? If so, list below. No known triggers INSECT STINGS (If local reaction ONLY, do not complete) N/A Suspected insect(s) that caused the reaction? Age at first reaction? # of reactions? How long after the sting did your symptoms occur? Symptoms with reactions: (Circle all that apply): local swelling shortness of breath wheezing passing out hives(other than at sting site) feeling of impending doom Treatment: ER Visits?: Were you given an Epi- pen? Yes or No Have you used the Epi- pen? Yes or No DRUG ALLERGIES List any medications that you are allergic to and what type of reaction? No Known Allergies MEDICATIONS Does your insurance require a 30 or 90 day supply of medications? 30 90 Please list all medications including strength and dosage. Include over the counter meds. *ALLERGY or ASTHMA medications taking PRESENTLY OTHER medications taking PRESENTLY Please list any previous allergy or asthma medications tried and the results. PAST MEDICAL HISTORY (Circle all that apply) Anemia GERD (reflux) Mitral Valve Prolapse Arthritis Glaucoma Nasal polyps Asthma Headaches Psoriasis Blood clots Heart Disease Rheumatoid arthritis Cancer (Type ) Hepatitis Seizures Cataracts Hiatal Hernia Chronic sinus infections COPD High blood pressure Sleep apnea 5

PAST MEDICAL HISTORY CONTINUED (Circle all that applies) Chronic ear infections Hyperthyroidism Stroke/TIA Hypoglycemia Hypothyroidism Tuberculosis Congestive heart failure High cholesterol Ulcerative colitis Diabetes Irritable bowel syndrome Eczema Kidney stones Fibromyalgia Lupus Gallstones Migraine headaches Illnesses not listed: Hospitalizations: Reason Date Reason Date PEDIATRIC HISTORY: For patients 0-12 years of age Birth weight: lbs oz Was birth premature? If yes, how many weeks? RSV before 3 months of age? Yes or No Reflux as an infant? Yes or No Multiple formula changes? Yes or No No SURGICAL HISTORY Surgeries: Tonsillectomy Yes Date Adenoidectomy Yes Date PE tubes Yes Date(s) No. of sets Polypectomy (nasal polyp removal) Yes Date Septoplasty (nasal bone repair) Yes Date Sinus Surgery Yes Date Other Surgeries FAMILY HISTORY (Please list IMMEDIATE family that have a history of the following) ALLERGIC FAMILY HISTORY Asthma Allergic rhinitis Sinus problems Nasal polyps Eczema Hives Food allergy GENERAL FAMILY HISTORY (Circle all that apply) Arthritis Cancer Heart Disease Hypertension Diabetes Emphysema Migraine Lupus Kidney disease Seizures Thyroid disease Tuberculosis Other illnesses not listed 6

Smoking status: Smoker Non- smoker Are you exposed to tobacco smoke? Yes or No If yes, how often? Current every day smoker/age started: /How many per day? Current occasional smoker/age started: /How many per day? Former smoker/ Age quit: counseling? Yes or No Do you use alcohol? Yes or No Do you use recreational drugs? Yes or No Tobacco type used: (Circle) Cigarettes Cigars Pipe Smokeless tobacco Quit date if less than a year ago: Have you had smoking cessation How often/how much? If yes, which ones? IMMUNIZATION HISTORY Are your immunizations up to date? Yes or No Did you receive your flu vaccine this year? Yes or No If yes, when? Have you received a pneumonia vaccine? Yes or No If yes, when? Have you received a tetanus booster in the last 10 years? Yes or No SOCIAL HISTORY City of residence Hometown: Most recent occupation Types of work done in past: Workplace Exposures: Please list If a child, grade in school: ENVIRONMENTAL REVIEW (Circle all that apply) Apartment Birds Carpet in bedroom House Cat indoors Feather pillow Mobile home Cat outdoors Cotton pillow Gas/Propane heat Dog indoors Zipper encasings Electric heat Dog outdoors Cotton mattress Fireplace No pets Feather mattress Space heaters Other animals: Tobacco/smoke exposure Central air Family members smoke indoors 7

REVIEW OF SYSTEMS (Circle the symptoms that you are currently experiencing) GENERAL Fever/nights sweats Weight loss SKIN Dry skin Rash/itching Hives HEENT Dry eyes Watery eyes Glaucoma Glasses/Contacts Good vision Nasal drainage Nasal congestion Nasal polyps Sinus pressure/pain Runny nose Sneezing Headache Ear infection Earache Ringing in ears Vertigo Hoarseness Sore throat Oral ulcers Snoring Sleep apnea/cpap RESPIRATORY Cough Shortness of breath Sputum production Wheezing Decreased exercise tolerance CARDIOVASCULAR Chest pain Swelling of extremities Difficulty breathing lying down Irregular heartbeat GASTROINTESTINAL Heartburn/indigestion Nausea/vomiting Abdominal pain Difficulty swallowing Bloody stools NECK Neck mass Swollen glands MUSCULOSKELETAL Joint swelling/pain Muscle weakness NEUROLOGICAL Stroke/tremor Dizziness PSYCHIATRIC Confusion Anxiety/depression ENDOCRINE Excessive thirst Excessive urination Thyroid problems HEMATOLOGY Anemia Nose bleeds Easy bruising FOLLOWING BLANKS ARE FOR PHYSICIAN COMPLETION ONLY: Reviewed by physician: (Signature) Date: 8