PEDIATRIC ALLERGY NEW PATIENT Patient Name Today s Date / / Date of Birth / / Age Sex Male Female Please tell us the reason for visiting the clinic today: Race/Ethncity: American Indian or Alaska Native Asian Black/African American White/Caucasian Hispanic/Latino Native Hawaiian or Other Pacific Islander Some other race or origin: Parents marital status Married Divorced Separated Single Custody arrangement: Who lives in the home with the child: Who referred your child to us? If a health care provider referred your child: Name Address Local Pharmacy: Name Address Phone Fax Phone Fax Primary Care Physician (if different from above): Name Address Mail Order Pharmacy: Name Address Phone Fax Phone Fax Page 1 of 11
PAST MEDICAL HISTORY Length of pregnancy: On or after the due date Before the due date (number of weeks early) Birth weight lbs. oz Type of delivery: Vaginal Planned C-section Emergency C-section Problems with the pregnancy? No Yes (specify) Were there problems during the birth? No Yes (specify) Did your child have breathing problems at birth? No Yes (specify) Was your child breast fed? No Yes (If yes, for how long) Was your child formula fed? No Yes (If yes, what kind of formula) Did your child have colic? No Yes Your child s growth pattern: Normal Rapid Slow Your child s development rate (sitting, crawling, walking, talking): Normal Delayed (explain): Are shots (immunizations) up-to-date? Yes No (explain): Did your child get the flu shot this year? Yes No Has your child had any of these illnesses? No Yes Age of Onset Number of Times Chicken pox RSV Ear infections Sinus infections Pneumonia Croup Other Illnesses (specify): Does your child have any chronic medical condition(s) besides allergies/asthma? Yes (please list) No Has your child ever had to stay overnight in the hospital? No Yes Month/Year Reason: Page 2 of 11
Has your child ever had surgery? No Yes Year Ear Tube(s) Tonsil Removal Adenoid Removal Sinus Surgery Other: FAMILY MEDICAL HISTORY Mother Age Job Animal allergy Seasonal nasal allergies Mold allergy Food allergy Insect allergy Other allergy Asthma Eczema Father Sibling 1 Boy/Girl Sibling 2 Boy/Girl Sibling 3 Boy/Girl Sibling 4 Boy/Girl Other family (grandparents, aunts, uncles, cousin) Do any family members have CF (cystic fibrosis)? No Yes Do any family members have any other type of lung disease? No Yes Specify Do any family members have other chronic medical conditions? No Yes Specify Page 3 of 11
SOCIAL HISTORY 1. What grade is your child in? 2. Does your child go to daycare? No Yes 3. Is your child home-schooled? No Yes 4. Does your child have a 504 plan? No Yes 5. Is your child in special education classes? No Yes 6. Has your child been in counseling? No Yes 7. Do you have a hard time getting your child to take medicines? No Yes 8. Are there any concerns for safety in the home? No Yes 9. Do you have any money concerns? No Yes 10. Do you have someone you can count on or talk to when you need help No Yes HOME ENVIRONMENT HISTORY: Please fill in information about where your child lives House, apt, condo, mobile (circle)? Age Years at residence Basement? No Yes Finished Unfinished Flooding: No Yes Carpet? No Yes wall-to-wall bedrooms Heating? Forced Air Electric Gas Baseboard Fireplace Wood-burning stove Air Conditioning? No Yes Central Window unit Swamp Cooler? No Yes Cleaned how often: Humidifier? No Yes Whole house or portable (circle)? Air Purification/Filter? No Yes Whole house or portable (circle)? Allergen-proof pillow & Mattress Encasings? No Yes Pets? (check all that apply) No Yes Dogs # Indoor Outdoor Indoor/Outdoor In Bedroom Cats # Indoor Outdoor Indoor/Outdoor In Bedroom Birds # Indoor Outdoor Indoor/Outdoor In Bedroom Other # Type: Indoor Outdoor Indoor/Outdoor In Bedroom Page 4 of 11
Does anyone in your house use tobacco? No Yes Father Mother Other(s): Would you like to receive FREE resources from the Tobacco Quitline? Does your child come into contact with any of these items in their home(s)? Mold Water Damage Leaking Roof Dirty Humidifier Other Exposures of Concern: None of the above HEALTH PROBLEMS (REVIEW OF SYSTEMS): Circle any of the problems your child has had over the past few months: ***PLEASE CHECK None if your child has not had any problems for certain sections.*** General Fatigue Daytime sleepiness Trouble sleeping Fever Chills Weight loss Poor weight gain Overweight Too short Too thin Loss of appetite Eyes Ears, Nose, & Throat Heart Lungs Gastrointestinal (GI) Blurred eyesight Burning Cataracts Dry Eyes Frequent blinking Watery eyes Itching Redness Swelling Lazy eye Near-sighted Far-sighted Wears glasses Snoring Hearing loss Ear pain Nasal polyps Nosebleeds Nasal drainage Itchy nose Sneezing Nasal/sinus congestion Dry mouth Post-nasal drip Mouth breathing Frequent sore throat Mouth sores Throat tightness Loss of sense of smell Chest pain Dizziness Murmurs Fainting spells Irregular heartbeat Palpitations Cough Cough at night Coughing up blood Chest tightness Frequent bronchitis/chest colds Wheezing Low oxygen level Shortness of breath during day AND/OR night Shortness of breath with exercise Frequent belly pain Indigestion Nausea Throwing Up Frequent spitting up Heartburn Acid taste in mouth Constipation Diarrhea Bloody stool Encoporesis pooping in pants Burping Gassiness Bloating Problem feeding Choking on food Choking while drinking Trouble swallowing Avoidance of certain textures: Slow eater Liver problems Yellow skin/jaundice Child complains food gets stuck Kidney/Genitourinary Bedwetting Wetting pants Frequent or Painful urination Menstrual Period: Onset: years Kidney problems Urinary stones Page 5 of 11
Muscles/ Bones Neurological Skin Hematology (Blood)/Lymphoid Fractures Back pain Joint pain Joint swelling Muscle pain Weakness Concentration problems Headaches Seizures Numbness Difficulty walking Tremors Weakness Rashes Eczema Skin infections Swelling Hives/welts Itching Hair Loss Low iron (anemia) Easy bruising Bleeding easily Blood clots Enlarged Lymph Nodes Unexplained lumps Psychological MEDICATIONS Nervous Worried Depressed Panic attacks Hyperactive Mood swings Stressed (why?): Does your child take medicines or supplements? No Yes fill in table below: Medicine Name Amount/Dose Route (by mouth, on skin, inhaled, etc.) Vitamins/Supplements How Often Taken in past month? Steroid Inhalers Asmanex Flovent Pulmicort inhaler Pulmicort (Budesonide) for nebulizer QVAR Alvesco Other: Combination Medications Advair Symbicort Dulera Page 6 of 11
Fast-acting Inhalers Ventolin, ProAir, or Proventil (albuterol) Atrovent Xopenex (levalbuterol) Combivent respimat Medication Name Dose Route How Often Taken in past month? Spiriva Singulair (Montelukast) Zyflo Oral Steroids (examples include Prednisone, Medrol, Prednisolone, Orapred, Prelone, Pediapred, Dexamethasone) Yes: Antihistamines Dose Route How Often Used in last month? Allegra (fexofenadine) Atarax (hydroxyzine) Benadryl (diphenhydramine) Clarinex (Desloratidine) Claritin (Loratidine) Xyzal (Levocetirizine) Zyrtec (Cetirizine) Nose Sprays Dose Route How Often Used in last month? Saline/Saline Washes Astelin/Astepro (Azelastine) Dymista Flonase (Fluticasone) Nasacort (Triamcinolone) Nasonex Rhinocort Veramyst Patanase Qnasl (beclomethasone) Omnaris (ciclesonide) Zetonna (ciclesonide) Afrin Eye Drops: Dose Route How Often Used in last month? Page 7 of 11
Patanol/Pataday Zaditor Other: Acid Reflux Medications Zantac (Ranitidine) Prevacid, Prilosec or Nexium Other: Please list ANY Other Medications: FOOD ALLERGY HISTORY if your child does not have food problems, please go to next page Is your child allergic to foods? No Yes Mark all that apply and specify reaction (age, symptoms, last known reaction): Milk: Egg: Soy: Wheat: Peanuts: Tree nuts: Shellfish: Fish: Other foods: Have you been prescribed an epinephrine auto-injector device? No Yes If yes: My child has the epinephrine injector near him % of the time Who carries it (circle all that apply)? Parent Child School Other: Is the epinephrine autoinjector with your child today? No Yes Number of ER visits for food allergy: Do you have a Food Allergy Anaphylaxis Action Plan? No Yes Does your child wear a medical alert bracelet? No Yes Have you seen a dietician before? No Yes If no, are you interested in meeting with a dietician? No Yes Is fear or worry about food a problem? No Yes Has your child been bullied because of food allergies? No Yes Page 8 of 11
Does your child avoid or refuse certain foods? No Yes Mark all that apply: Milk Egg Soy Wheat Peanut Tree nuts Shellfish or Fish Does your child have feeding problems? No Other (specify): Yes: Is your child on a nutritional supplement or formula that makes up more than half of his/her diet? No Yes: DOES YOUR CHILD WHEEZE WITH COLDS OR HAVE ASTHMA? - If no, please go to page 11. If yes, please answer these questions: Symptoms (cough, wheeze, etc) Nighttime awakenings 2 days/week >2 days/week but not daily Daily Throughout the day Age 0-4: 0 1-2x/month 3-4x/month >1x/week Rescue inhaler use (not to prevent exercise asthma) Age 5: 2x/month 3-4x/month >1x/week but not nightly 2 days/week >2 days/week but Daily not daily Often 7x/week Several times per day Asthma Attacks needing oral steroids (prednisone, Orapred, prednisolone, etc) 0-1/year Age 0-4: 2 in 6 months OR wheezing 4x per year lasting >1 day Age 5: 2/year Hospitalizations due to asthma No Yes Total number: Most recent: History of ICU admission for asthma? No Yes Page 9 of 11
1. Does your child take daily asthma controller medicines? No Yes How many doses of the daily controller medications are missed in a normal week? 2. Do you feel like your child s asthma is under control? No Yes 3. Does your child see another specialist for this problem? No Yes 4. How old was your child when wheezing first started: 5. What are the main triggers for your child s wheezing episodes? Colds Exercise Pollen Pets Other(s): 6. Is your child able to keep up with others during physical activity? No Yes 7. Has your child ever been intubated (on a respirator with a breathing tube)? No Yes 8. Does your child use any of the following? Spacer Nebulizer Peak Flow meter Personal best: 9. Do you have an Asthma Action Plan and rescue medication at school/daycare and/or home? No Yes Page 10 of 11
OTHER ALLERGIC PROBLEMS: NO YES Is your child allergic to: Animals? Cats Dogs Other: Medicines? Specify: Insect stings? Specify: Latex? Specify: Does your child have: Nasal allergies? When? Spring Summer Fall Winter Eye allergies? When? Spring Summer Fall Winter Does your child have: Atopic dermatitis (eczema)? Has your child seen a skin doctor? Yes No Frequent scratching? Frequent hives or swelling? If your child has skin problems: Does your child take baths or showers? For how long? What kind of soap is used? What kind of lotions/moisturizers are used, and how often? What kind of medicated skin lotions or creams are used? Has your child been prescribed antibiotics for skin infections? Has your child had to use wet wraps before? Do skin symptoms make it hard for your child to sleep? Past Allergy Testing: No Yes Location and Date: Parent/Legally Authorized Representative Signature Date Page 11 of 11