Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE

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Page 1 of 5 Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE NAME: AGE: DATE OF BIRTH: Primary/Referring Physician: Phone #: Other Subspecialists participating in care: I. MAIN PROBLEM TO BE ADDRESSED: (please check all that apply) Asthma Hay Fever Sinus Problems Infections: Cough Headaches Swelling (skin) Blood Eczema Hives Food Allergy Bone Fire Ant Stinging Itching (skin) Ear Food Allergy Lung Sinus OTHER: Skin Throat When did the problems begin? How often do they occur? What makes it better? What makes it worse? Is it worse during the morning?, noon/afternoon?, and/or nighttime? During which months is it most severe? Jan Feb Mar April May June July Aug Sept Oct Nov Dec What do you think triggers the problem? Cats Dogs Grass Pets Stress Cigarette smoke Dust Heat Perfumes Cold Food Mold Scents OTHER: _ II. ALLERGY REVIEW: YES/NO YES/NO YES/NO Nasal congestion Bad breath Heartburn Runny nose Sinus infections Hoarseness Sneezing Ear infections Itching (skin) Loss of sense of smell Cough Swelling (skin) Itchy/watery eyes Wheezing Prior allergy tests Drainage down the throat Shortness of breath: If yes Date Frequent throat clearing with exercise M.D. name Colored Nasal Discharge at night time Prior allergy shots E.R. visits for asthma Hospital stays for asthma # If yes Date Number in last year Number in last year M.D. name Most recent visit Most recent hospitalization Oral steroid requirement for asthma Most recent course

Page 2 of 5 DRUG ALLERGIES REACTION DATE NOTED 1. 2. 3. FOOD ALLERGIES REACTION DATE OF LAST EPISODE 1. 2. 3. CURRENT FOOD AVOIDANCES: OTHER ALLERGIES: REACTION DATE NOTED X-Ray Dye Latex (rubber) INSECT STINGS (please describe reaction): III. Birth History: Product of full term pregnancy Vaginal delivery C-Section Complications before/during/after delivery Required prolonged hospitalization after delivery YES/NO IV. Past medical history (please list all diagnosis): 1. 7. 2. 8. 3. 9. 4. 10. 5. 11. 6. 12. V. Immunization History: Up to date. Records in chart. VI. Hospitalizations or Operations Type Year Reason

Page 3 of 5 VII. Family History: (Please include pertinent conditions including asthma, allergies, spontaneous miscarriages, Early infant deaths, recurrent infection). Age Medical Problems Pertinent Conditions Father Mother VIII. Social history: 1. Live at home with: Mother Father Siblings 2. Secondary tobacco exposure? Yes/No If yes, who smokes (Please include all family members) 3. Preschool. Yes/No (please circle appropriate response) Daycare. Yes/No School: (Name and Grade) 4. Number of days absent due to asthma, allergy or infection in past year. 5. Pets: (circle appropriate response(s) inside, outside, both, sleep in bedroom.) (Dog/Cat/Other) Increased allergy symptoms around animals? Yes/No 6. Age of home:. 7. Flooring: (please circle appropriate response(s) carpet, tile, hardwood, throw rugs, other: ) 8. Bedroom furniture: (please circle appropriate response(s) box spring/mattress, waterbed, stuffed chair, throw pillows, down pillows and/or comforter, tapestries). 9. Window coverings: (please circle appropriate response(s) cloth, wood blinds, metal/plastic blinds.) 10. Do you have (please circle appropriate response(s) ceiling fan, box fan, oscillating fan.) 11. Do you have evidence of (please circle appropriate response(s) water damage (floods, leaks) in your home? Yes/No 12. Does your home have (please circle appropriate response(s) central air/heat/window units.)

Page 4 of 5 PATIENT HISTORY: REVIEW OF SYSTEMS Please check any problems (boxes) listed below which have significantly affected your child. (If left unchecked the presence of the problem is denied). Person completing form Patient Mother Father Legal guardian Other Patient s Name Constitutional Recent weight gain (amount) Recent weight loss (amount) Fever Frequent Infections Type of Infections: Throat Infections Ear Infections Sinus Infections Pneumonia Blood Infections Skin Infections Bone Infections Eyes Pain Redness Itching eyes Ears Nose Mouth Throat Nosebleeds Loss of smell Dryness in nose Runny nose Oral Thrush Hoarseness Cardiovascular High blood pressure Heart murmurs Shortness of breath Respiratory Cough Wheezing Gastrointestinal Date Vomiting Persistent diarrhea Reflux Genitourinary For Women Only: Age when periods began: Periods regular? Yes No How many days apart? Date of last period? / / Dermatologic (skin) Hives Eczema Rash (other) Yeast Infections Neurological System Headaches Musculoskeletal Joint pain Joint swelling Physician Initials Parent Signature

Page 5 of 5 Drug allergies: No Yes To what? MEDICATIONS Type of reaction: PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.) Name of Drug Dose (include How long Please check: Helped? strength & have you number of pills taken this A Lot Some Not At All per day) medication 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Natural or Alternative Therapies (chiropractic, magnets, acupuncture, massage, over-the-counter preparations, etc.) Specially for Children Pediatric Allergy, Asthma, & Immunology Jackee Kayser, MD & Howard Rosenblatt, MD Modified from Patient History Form 1999 American College of Rheumatology

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