Adult Allergy & Medical History

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Adult Allergy & Medical History Ridhu C. Burton, M.D. How did you hear about our office? Referral by another physician Referral by another patient Phonebook listing Internet Ad; Please circle one Google, Bing or Yahoo Other: Name: Birth Reason you were sent to an Allergist: Prior allergy tests (date & where): Prior allergy injections (date & where): Prior Chest x-ray/ct (date & where): Do you now or have you had any problems related to the following? Circle Yes or No. Diabetes Y N Hypertension (high or low blood pressure) Y N Cancer Y N Stroke Y N Convulsions Y N Heart Disease Y N Asthma Y N Arthritis/Gout/Rheumatism Y N Lung disease Y N Blood Disease Y N Kidney Disease/Stones Y N Peptic Ulcer/ GERD Y N Constitutional symptoms Gastrointestinal Fever Y N Heart burn/indigestion Y N Night sweats Y N Abdominal pain Y N Weight change Y N Nausea/vomiting Y N Eyes Diarrhea/constipation Y N Cataracts Y N Cancer/Tumor Glaucoma Y N Location Contact Lenses Y N Urologic Neurologic Prostate enlargement Y N Migraines Y N Urinary infections Y N Cardiovascular Respiratory Irregular heart beat Y N Croup Y N Chest Pain/Angina Y N Obstructive sleep apnea Y N Pacemaker Y N Skin Palpitations Y N Eczema Y N Endocrine Hives Y N Thyroid disease Y N Psoriasis Y N Osteoporosis Y N Immunologic Elevated cholesterol Y N Recurrent infections Y N

Psychological HIV Y N Blood transfusion Y N Depression Y N Immunizations Complete Y N Anxiety Y N Past Surgeries and dates, if known: 1. Year 4. Year 2. Year 5. Year 3. Year 6. Year I. Living Environment-Circle the following A. Type of structure: Home Apartment Mobile Home Location of Home: Urban Rural Suburban Proximal to: Factories Granaries Farm Approximate age of home: How long have you lived there? Any smokers in residence? Yes No B. Do you have the following: Basement Crawl Space Slab Type of basement: Block Poured Finished Michigan cellar Basement in winter: Dry Damp Basement in summer: Dry Damp Basement musty or moldy: Yes No Basement leaks with rain: Yes No Dehumidifier in basement: Yes No Symptoms worse in basement: Yes No Ridhu C. Burton, M.D. C. Type of Furnace: Gas Wood Oil Electric Coal Location of furnace: Basement Crawl space 1 st floor Heating system: Forced air Radiator Steam Fireplace Space heater Type of Filters: Disposable Permanent Electrostatic How often is filter changed: Central air conditioning: Yes No Room air cleaner: Yes No Humidifier on furnace: Yes No Portable humidifier location Fireplace or wood burning stove: Yes No D. Patient s Bedroom location: Basement 1 st floor Upper floor Bedroom Floor coverings: Carpet (shag) Carpet (short pile) Wood Tile Vinyl Living Area Floor coverings: Carpet (shag) Carpet (short pile) Wood Tile Vinyl Bed coverings: Feather comforter Yes No Pillow(s): Polyester Foam Feather Cotton Pillow age Are pillows encased? Yes No Mattress: Cotton innerspring Foam Water Feather Mattress age Is Mattress encased? Yes No Is Box Spring encased? Yes No Pets in bedroom: Yes No E. Is there mold growing anywhere in the house: F. Is there anything in your building, yard, or around your house that has not been mentioned that you think is significant in contributing to your problems?

II. Inhalant History A. Dust: Dust exposure may cause either Nasal or Lung symptoms or both. With the following dust exposures, indicate which symptoms are worse by circling N to indicate Nasal, L to indicate Lung, O to indicate None, and U to indicate Unknown. Dusty garage: N L O U Breathing house dust: N L O U Outdoor dust: N L O U Dusting and/or vacuuming: N L O U Feathers N L O U B. Molds/Pollens: Do your symptoms worsen after exposure to the following: Hay: Yes No Unknown Raking Leaves: Yes No Unknown Barns: Yes No Unknown Cut grass(dried/fresh): Yes No Unknown Damp Basements: Yes No Unknown Eating mushrooms: Yes No Unknown Eating cheese: Yes No Unknown C. Danders: Please indicate the number of pets you own, their age and circle whether they are indoor or outdoor? Cat # Age Outdoor/Indoor/Bedroom Dog # Age Outdoor/Indoor/Bedroom Parakeet # Age Outdoor/Indoor/Bedroom Other # Age Outdoor/Indoor/Bedroom What animals aggravate your symptoms? Are you exposed to animals in your workplace? Yes No If so, what animals? D. Miscellaneous: Which, if any of the following produce onset or an increase in symptoms? Aerosols (sprays) Nose Chest Both Newspaper print Nose Chest Both Perfumes Nose Chest Both Tobacco smoke Nose Chest Both Strong chemical odors Nose Chest Both Detergent powders Nose Chest Both Diesel/gasoline fumes Nose Chest Both E. Physical Agents: Do you have onset or increase of symptoms after exposure to the following? Temperature change Yes No Onset Increase Exercise Yes No Onset Increase Drafts Yes No Onset Increase Sunlight Yes No Onset Increase Weather changes Yes No Onset Increase Dampness/rain Yes No Onset Increase Wine/beer Yes No Onset Increase Barometric pressure change Yes No Onset Increase

III. Do foods cause any symptoms? A. Name Food and Associated Symptoms IV. Social History A. Please indicate amount of use where applicable Alcohol Coffee/caffeine Recreational drugs Hobbies (hives, rash, runny nose, nausea, vomiting, diarrhea, headache) Smoking Current Past Never Total number of years of smoking If you were a smoker, date quit Average packs per day (cigarette, cigar, pipe) V. Drugs A. Have you ever had an adverse or allergic reaction to any medication? Drug Reaction Date VI. Insect Stings: A. Have you ever had an unusual reaction from an insect sting? Yes No Type of insect Type of reaction: VII. Prescription Pharmacy (please choose a pharmacy if you do NOT currently have one) 1. Local Pharmacy: Address: Phone #: Mail Order Pharmacy:

VIII. Medications A. List all current medications including strength and how often you take it: Med Name: Strength (i.e. mg): Frequency: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. IX. Have you had the Influenza Vaccine? What was the date of your last Influenza Vaccine? No Yes Please list any other vaccines you have had: (pneumonia, shingles etc.)

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