(pedi) Patient Name: date of birth:_ Date: I am being seen on: a) self referral _ b) physician referral from Dr. Please share the main reasons for your office visit today (check all those that apply): a) Allergic rhinitis (runny and/or stuffy nose) e) Atopic dermatitis (eczema) _ b) Allergic conjunctivitis (red, itchy eyes) f) Nasal polyps _ c) Asthma g) Urticaria (hives) _ d) Bronchitis h) Frequent sinus infections _ i ) Other What you would like to accomplish today? a) Review my current illness and treatment b) Obtain allergy testing c) Obtain information on asthma diagnosis and treatment d) Other _ HISTORY OF PRESENT ILLNESS (please fill in all sections which apply to you or your family member): My symptoms began : My symptoms are: days ago Seasonal: (Worse during a certain season? Check which season is worse) weeks ago Spring months ago Summer years ago Fall Winter Perennial (equal all year) with no seasonal change Perennial (equal all year) with seasonal exacerbations in the: Spring Summer Fall Winter Please check which of the following symptoms are present: NOSE: EYES: Nasal congestion (blockage) Redness: Mouth breathing at night: Watering: Itchy nose: Sensitivity to light: Bloody nose: Itching: Sneezing: Snoring: HEADACHE: Poor sense of smell: Location (front, side, back) Drippy/runny nose: Quality (sharp, dull, achy) Drainage in back of throat: EARS: LUNGS: Itching: Shortness of breath: Frequent infections: Wheezing: Congestion (stuffiness) Cough: SKIN: Hives: Eczema: Swelling of face:
Triggers that I know worsen my symptoms include: 2 No known environmental triggers _ Non-specific environmental triggers: Specific environmental triggers: Weather changes Indoor dust: _ any weather change Outdoor dust: _ hot and dry weather Mold spores: _ cold and wet weather Animal dander Tobacco exposure cat Perfumes and propellants dog Other other All pollens tree pollen grass pollen weed pollen other pollen ALLERGY HISTORY: Allergy testing has: I have never been on allergy injections never been pursued I am currently on allergy injections is scheduled These began months ago has previously shown years ago no allergies allergy to: I previously received allergy injections pollen These were given years ago dust I continued these for years mold pets other _ Have you had experience with any of the following medications? If so, did they help? TYPE OF MEDICATION RESULT EXAMPLES (i.e., Claritin, Flonase, etc.) GOOD BAD Antihistamines Decongestants Antihistamine/Decongestants Nose sprays Eye drops Have you had allergic reactions to medications or foods? DRUG REACTIONS: Name of medication Type of reaction (skin, respiratory, stomach symptoms, etc.) 1) 2) 3) FOOD REACTIONS Name of food Type of reaction 1) 2) 3)
PAST MEDICAL HISTORY 3 Hospitalizations and/or surgery: Age or year for Other chronic health conditions (Please specify) Please list all of your current medications: Name of medication Route, dose & frequency Indication (i.e., 10mg each morning) (i.e., for blood pressure) 1) 2) 3) 4) 5) FAMILY HISTORY (Please check if your family member is or has been affected by the following illnesses): Asthma or Allergic rhinitis Atopic dermatitis Urticaria Chronic bronchitis (hayfever) (eczema) (hives) Mother Father Brother Sister Other relatives SOCIAL HISTORY: Parents marital status Married Separated lives with mother lives with father other _ Divorced lives with mother lives with father joint custody other _ Members of household mother father brother(s) (how many) sister(s) (how many) other(s)
Name of daycare/school Grade level/classification _ daycare/preschool grade school middle school high school 4 Extracurricular activities/hobbies: Employment (if applicable): sports where band/choir/orchestra position cheerleading 4-H other _ TOBACCO HISTORY: Cigarette smoker/or exposure (check all that apply): Exposure to cigarette smoke _ Non smoker Smoker Ex-smoker quit how long ago weeks _ months _ years _ pack/day for _ years _ Other tobacco use ENVIRONMENTAL HISTORY: The patient lives in a(n): house apartment other _ The home is in: town the country other Indoor exposure to the following is present: Pets: Heating/Air-conditioning: cats _ central heat/air dogs _ evaporative cooler other gas heat/furnace other Bedding: boxspring mattress waterbed other _ Carpeting in bedroom
ASTHMA (Please skip this page if you have never had breathing problems) Asthma has: never been previously diagnosed, but is suspected _ been diagnosed in childhood _ at age been diagnosed in adulthood _ at age My compliance with medications: I currently use the following: is always excellent a spacer attached to my inhaler is intermittently good a peak flow meter to measure breathing is poor because: a written asthma action plan I hate to take any medication I am concerned about side effects medications are too expensive medications have not helped me in the past other Triggers for my asthma symptoms include: no obvious exposures pollens cigarette smoke sinus infections animal dander weather change exercise dust respiratory infections/colds other Asthma medications I have had previous experience with include: ASTHMA RELIEVERS Response Quick-acting Good Bad Leukotriene modifiers (cont d) Good Bad Albuterol Zyflo Xopenex Mast cell stabilizers Maxair Intal Atrovent Tilade Combivent Combination drugs Long-term Advair Foradil Symbicort Serevent Theophylline ASTHMA CONTROLLERS Slo-Bid Inhaled steroids UniDur Aerobid Uniphyl Azmacort Oral Steroids Beclovent Prednisone Flovent Medrol Pulmicort Prelone Vanceril Pediapred Leukotriene modifiers Other medications Singulair Accolate