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Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST BRING AN UP-TO-DATE AND ACCURATE LIST OF ALL MEDICATIONS THEY ARE CURRENTLY USING OR HAVE TAKEN IN THE PAST 6 MONTHS (including dosages)****** 0602188 (5/12)

Page 2 of 7 Age: Weight: Height: Occupation: Please list the main reasons for your visit today: Do you have any of the following systems? (Circle) sneezing blocked nose watery nose shortness of breath wheezing chest tightness cough sputum (phlegm) night symptoms severe itching severe swelling acid stomach Have you been told or think you have any of the following? (Circle) sinusitis ear infections nasal polyps recurrent bronchitis eczema hives stomach refl ux allergic rhinitis / hay fever diabetes tuberculosis frequent infection high blood pressure Which of the following bring on attacks of allergies and asthma? (Circle) respiratory infection cold air Allergens: occupation chemicals exercise pollens emotions-stress weather changes dust tobacco-smoke strong odors mold Other triggers: dog cat What months are your symptoms worse? (Circle) Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. None

Page 3 of 7 Symptoms worsen: (Circle) At night Mornings Evenings At home At work Indoors Outdoors Other Allergies? (List) Medications: Foods/Food additives: Insects (Describe reaction): Latex (rubber products): Hobbies: Indoor: Outdoor: History of any prior Allergy evaluations? Yes No If so, when and where: Skin test results: Previous Allergy Injections? Yes No Dates Current medications: (please list medication and dose): *** A reminder to please bring a list of medications prescribed by your allergist Smoking: Do you smoke? Yes No Date stopped Number of years smoked? Approximate number packs/day Family History Allergy in close relatives: Yes No List them: Asthma in close relatives: Yes No List them:

Page 4 of 7 Environmental History How long in current home? Apt. How old? Location: City Suburb Rural Is there a basement? (circle damp or dry) What kind of heating system? Radiator/baseboard Hot air Bedroom: What floor is bedroom on? Bedroom carpeted? Type of pillow: Type of comforter: Any Down Y or N Mattress: Inner spring Futon Water Foam Do you have allergy-proof covers for your pillows? Mattress? Flooring: Hard Wood: Area rug: Wall to Wall: Air conditioning: Central Separate units Humidifi er: Animals in home: Yes No List: Tobacco smoke in home? Yes No Who? If you suspect you have asthma, please answer the following Nighttime wheezing, cough, shortness of breath: Often Occasional Never Limitations and symptoms: With sports or strenuous exercise: With any activity: Symptoms are present at rest Number if school/work days missed during last year (appropriate) Number of oral steroid (prednisone) prescriptions in last year (Approximate): Number of visits for asthma (lifetime) to emergency room: History of Life threatening attacks? Yes No Intubated: Yes No Have you had any other serious illness, accidents, or hospitalizations? If so, when? Are you pregnant or planning on getting pregnant? Please list any questions/concerns that you would like discussed during this visit and list what you would like to accomplish with today s visit?

Page 5 of 7 Have you (or child for whom you are fi lling out this form) ever felt unsafe or been afraid of anyone (i.e. your partners, a relative, or anyone else? Do you experience pain as part of your daily life? If yes, describe the location(s); onset; durations; and characteristics of your pain (i.e. ache, burn, throb, sharp). If yes, on a scale from 1-10, 10 being the greatest pain, how would you describe this pain? If yes, how do you treat your pain? Do you have a Health Care Proxy, Advance Directive or Living Will? If yes, please identify: Reviewed by: Date Time Physician MD CID

Page 6 of 7 REVIEW OF SYSTEMS IN THE LAST 12 MONTHS, HAVE YOU HAD ANY OF THE FOLLOWING: GENERAL Yes No BONES/JOINTS Yes No Fevers Chills EYES Large Weight Change Enlarged Lymph Nodes Itchy Watery Eyes Red Eyes Blurry Vision EAR/NOSE/THROAT Ear popping Diffi culty hearing Post-nasal drip Sinus pain/pressure CARDIOVASCULAR Heart palpitations Abnormal heart rhythm Chest pain Swollen ankles RESPIRATORY Shortness of breath Chronic cough Wheezing Chest Tightness GASTROINTESTINAL Heartburn/refl ux Nausea/vomiting Diarrhea SKIN Painful joints Back pain Eczema Dry skin Sensitive skin Hives Rashes GENITOURINARY Frequent urination Pain with urination Abnormal menses (women) ENDOCRINE Heat Intolerance Cold Intolerance Excess thirst NEUROLOGICAL Fainting spells Dizziness Seizures PSYCHOLOGICAL Increased stress Depression Anxiety Suicidal thought OTHER Reviewed by: Date Time Physician MD CID

Page 7 of 7 Did you receive a copy of the We Care About Your Safety brochure? Yes No Do you understand how to prevent the spread of germs? Yes No Reviewed by: Date Time Physician MD CID

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