Aair Allergy/asthma Patient Medical History (Page 4 of 4) in pdf

Name___________________________

VIII. FAMILY HISTORY: Please check all conditions that occur in your family and indicate who is/was affected.

Asthma

info________________________________________

Nasal Allergies

info________________________________________

Sinus Disease

info________________________________________

Food Allergy

info________________________________________

Eczema

info________________________________________

Hives / swelling

info________________________________________

Insect sting allergy

info________________________________________

Immune deficiency

info________________________________________

COPD/emphysema

info________________________________________

Cancer

info________________________________________

Heart disease/stroke

info________________________________________

Other family history:________________________________________________________________________________________

IX. SMOKING HISTORY/EXPOSURE:

Current smoker

Former smoker

hand smoke exposure

1. How many years total?_________

How many packs per day on average?____________ When did you quit?_____________

2. Anyone who lives in your house or visits often a smoker? (even outdoors)

Y N Who?______________________________

3. Did parents/caregivers smoke growing up?

Yes No Who? _________________________

X. ENVIRONMENTAL/ SOCIAL HISTORY:

Married

Single

1. Occupation_______________________________ Parents occupations (if minor) ______________________________________

Attending school Grade_______

Attend Day care/Babysitter? # of days per week___________

If minor, if parents are separated, number of days/month at: Mother’s home________ Father’s home_________

Hobbies______________________________

Chemical exposures at home or work _______________________________

2. PETS- What pets do you own or have significant exposure to?

Cat number_______ #of years________

indoor

outdoor

Sleeps in Bedroom

Ever goes in Bedroom

Dog number_______ #of years________

indoor

outdoor

Sleeps in Bedroom

Ever goes in Bedroom

Birds what type?______________________________________

Horse

Aquarium

Rabbit Hamster Guinea Pig

Cow Pig Sheep Goat

Other___________________________

3. What animals are you exposed to: At parents/relatives homes? __________________________ how often?________________

At school/daycare/babysitters? ________________________ how often?________________

Ever exposed to/had in home?:

Mice

Fleas

Cockroaches

Rats ___________________

4. How long have you lived in Upstate NY?___________________ Years in current home________ Age of home ____________________

Previous locations lived_________________________________________________________ date of last move:___________________

5. Any damp/musty areas in home?

N Y where? __________________________________

Any prior water damage?_______________

Any visible mold?______________________

Any prior mold removal?

N Y how fixed? _____________________________

Basement:

Finished basement

Bedroom in basement

playroom in basement

office in basement

________________________

have Dehumidifier

Ducts last cleaned___________

Furnace filter changed____________

6. Cooling:

Central air conditioner

Room air conditioner

Home windows open when hot

Heating: Type of heating system:________________________

Wood burning stove

Fireplace

7. Do you live:

near open fields

in/near wooded area

near a farm

exposure to Barns

near highway/major roads

Do you spend time:

Gardening

camping

at a cottage/lake house/second home where?_________________________

8. Carpet:

Wall-to-wall carpeting

Carpet in bedroom

Rug in bedroom

Stuffed toys number________ how many on bed?________

10.

Feather/down pillow

Feather/down comforter

Down Jacket

11. Is Cancer screening up to date for age (ex Pap smear, mammogram, Prostate, colonoscopy ect)

Yes

N/A

Any previously abnormal?____________________________________________________

X. REVIEW OF SYSTEMS: (Please check any that has been a recurrent or chronic problem for you).

General:

Unintentional weight loss Fevers Chills Fatigue Poor concentration

Snoring

Stop breathing at night

HEENT:

History of Glaucoma

Vision changes

Dry eyes/mouth

Frequent nose bleeds

Oral ulcers

Cardiovascular: Chest pain

Chest/arm pain with exercise

Ankle swelling

Sleeping with more than 2 pillows to breathe

Gastrointestinal:

Heartburn

belching difficulty swallowing

nausea/vomiting

Diarrhea

bloody/tarry stools

GU:

Urinary retention

Excessive bleeding

Change in menstrual cycle

Worsening of symptoms with menstrual cycle

Endocrine:

Thyroid problems

Cold intolerance

Heat intolerance

Diabetes

Musculoskeletal: Painful, swollen joints

Morning joint stiffness

Muscle weakness

Persistent swollen lymph nodes

Neurological:

Depression

Anxiety Behavior problems

Frequent/severe headaches

Fainting/dizziness

_______________________________________________________________________________________________

Physician notes:

__________________________________________________________________________________________________________

Physician Reviewed_________________________________ Date___________

Aair Allergy/asthma Patient Medical History Page 4

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