Histsend.hcfa 10.17.07 Reviewed form with patient ________

ASTHMA & ALLERGY CARE OF DELAWARE, P.A.

W.J. Geimeier, M.D. R. Kim, M.D. G.V. Marcotte, M.D. Q.C. Nguyen, M.D. A.G. Weinstein, M.D.

Patient History Form - Send Out

Please fill out this form prior to your visit to us and bring it with you to your appointment.

Patient’s name:_________________________________________ Age:________________ Referred by:____________________________________________ Date:_________________

Other doctors to whom reports should be sent:___________________________________________ 1. Why are you coming to see us?____________________________________________________________ _________________________________________________________________________________________ 2. We will do our best to find out what is causing your problems and help you to feel better by giving you tips to avoid

allergens and irritants and/or how to use medications to treat your symptoms. Besides this, is there anything else you expect from your visit here?

_____________________________________________________________________________________________ _____________________________________________________________________________________________ 3. If you have respiratory symptoms indicate the pattern:

Head/Nose Chest Year round, no seasonal variation _____________ _____________ Year round, worse seasonally _____________ _____________ Seasonally only _____________ _____________ If seasonal, list months _____________________________________________________________________________ 4. Do you note increased symptoms from any of the following:

a. ALLERGENS b. IRRITANTS

Mowed Grass _____ Dead Grass _____ Dead Leaves _____ Hay _____ Mold _____

House Dust _____ Cats _____ Dogs _____ Feathers _____ Others ___________

Perfumes _____ Soaps _____ Detergents _____ Newspaper print _____

Smoke _____ Paint _____ Hair Spray _____ Outside Dust _____ Other _____________

c. WEATHER CHANGES

d. INGESTANTS

Windy Days _____ Temp. Change ____ Alcohol _____ Cold Fronts _____ Damp weather ____ please list specific ingestants

Patient Name:____________________________________________ Page 2

Histsend.hcfa 10.17.07 Reviewed form with patient ________

5. Past Medical History: Please list any medical problem/diagnosis you have (such as glaucoma, cataracts, sinusitis, nasal polyps, thyroid problems, high blood pressure, heart disease & arrhythmias, gastric reflux (heartburn), osteoporosis, prostate problems etc.)

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6. Please list any hospitalizations or surgeries you have had with approximate dates.

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7. Medications: Please list any prescription or over-the-counter medicines, nose sprays, eye drops, herbs, or nutritional supplements you take daily or occasionally. Please include dosages and frequency (ex: benadryl, 25 mg every 6 hours as needed).

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8. Drug Allergies: Are there any medicines you avoid because of allergic or adverse reactions? (please include name of med, approximate date of reaction, and what the reaction was, ex: penicillin, 1998, hives and shortness of breath). _____________________________________________________________________________________________ _____________________________________________________________________________________________ 9. Are you allergic to any foods? No ___ Yes ___ Please explain:_________________________________________ 10. ……. to insect stings? No ___ Yes ___ Please explain:_______________________________________ 11. ...…. to latex? No ___ Yes ___ Please explain:_______________________________________

Patient Name:____________________________________________ Page 3

Histsend.hcfa 10.17.07 Reviewed form with patient ________

Family History: 12. Is there a family history of allergy?

Type of disease relative(s) affected (mother, brother, etc.) Hayfever (allergies) _____________________________________________________ Sinus problems _____________________________________________________ Asthma _____________________________________________________ Eczema (atopic dermatitis) _____________________________________________________ Nasal polyps _____________________________________________________ Hives or swelling _____________________________________________________ Food allergy _____________________________________________________

13. Are there any other major medical problems in the family? (Heart disease, diabetes, cancer etc.) _____________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Social History: 14. Have your allergy problems caused you to miss school / work? Y / N How many days per year? _____ 15. Smoking __ I have never smoked

__ ex-smoker (When did you quit?______ How long did you smoke?______ How many packs per day?____ ) __ current smoker (How long have you been smoking?___ How many packs per day?____)

16. Do you use drugs or alcohol? ______ How much per day or per week?________________ . 17. What are your hobbies? ______________________________________________________________________

Do any of these make your symptoms worse?___________________________________________________

18. Is there anything at work/ school that makes your symptoms worse? ______________________________________ Children: 19. Up to date on shots? Y / N Height & weight stable? Y / N How many weeks at birth (40?) ___ Adults: 20. Are you single married partnered separated divorced widow(er)? 21. What is your occupation? (If retired, what was your main occupation?) ______________________________ 22. Immunizations: last flu shot?___ tetanus/diptheria?___ pneumonia? ____

Patient Name:____________________________________________ Page 4

Histsend.hcfa 10.17.07 Reviewed form with patient ________

Environmental Survey

Living Accommodations: City ____ Apartment ____ Suburbs ____ House ____ Country ____ Trailer ____ Present address for ________ years Basement and/or crawl space: None: ____

Dry ____ Damp ____ Does your home have any damp or musty areas? None ___ Basement ____ Family room ____ Bedroom ____ Bathroom ____ Kitchen ____ Furniture:

Wood, vinyl or leather _____ Upholstered/stuffed ____

Carpet: Wall to wall ____ Area ____ Bedroom: Carpet: Wall to wall ____ Area____ Mattress: Age ____ Rubber ____ Regular ____ Water ____ Pillow: Feather ____ Rubber/synth. ____ Blanket: Wool ____ Cotton/synth. ____ Comforter/Afghan: Down ___ Polyester/synth.___ Wool ____

Window Coverings: Curtains ____ Shades ____ Blinds ____ Allergy proof covers ? None ____ Pillows ___ Mattress ___ Box Spring ___ Dust Collectors: Wall hangings ___ Stuffed animals ___ Books ___ Climate Control: Fuel:

Gas ____ Oil ____ Electric____ Wood ____ Home Heating: Hot water/steam/radiator _____ Forced hot air_____ Electric baseboard _____ Kerosine Heater _____ Furnace Filter: Change_____ x a year fiberglass ___ aluminum ___ electrostatic ___ HEPA ___ Air Purifiers: None ____ Yes____ Where?_____________________________ What type? _________________________ Dehumidifiers: None____ Yes____ Where? __________________________ Humidifier: None ____ Central________ Portable Unit_________ Where? ____________________________ Air Conditioning: None ____ Central ____ Unit (which rooms?)________ House plants: None ____ Livingroom, how many? ________ Bedroom, how many? ________ Other: Animal Contact: None ____

Indoor Outdoor Dog _________ _________ Cat _________ _________ Bird _________ _________ Mice _________ Horse ________ Other ________ _________ Have you ever noticed cockroaches or waterbugs

at home? Yes ____ No ____ at work/school? Yes ____ No ____

Smoking: How many smokers are there in the house? _____

Who smokes? ___________________________