Patient’s Name ______________________________________________
Date of Birth _______________________________
Date of Visit ________________________________
ENVIRONMENTAL/ SOCIAL HISTORY:
Age of home: _____________________ years
Basement:
 Yes  No
Air Condition:
 Yes  No
Humidifier:
 Yes  No
Dehumidifier:
 Yes  No
Air Purifier:
 Yes  No
Filters Changed:
 Yes  No
Lived in home: _____________________ years
Smokers:
 Yes  No
Carpeting:
 Yes  No
Occupation: ______________________________
Mattress Encasing:
 Yes  No
Pillow Encasing:
 Yes  No
Pets:
 Yes  No
# of dogs: ________ # of cats: __________ # of others: _________
Do you smoke/smokeless tobacco?
 No  Yes
If you have quit smoking, when did you quit? _____________________________________________________
Number of packs per day: _____________________ Number of years smoking: ______________________
Do you drink alcohol?
 No  Yes
Are you currently pregnant?
 No  Yes
Are you planning a pregnancy?
 No  Yes
REVIEW OF SYSTEM: Please check off any symptoms you currently experience:
General
 Fatigue
 Weight loss
 Loss of appetite
 Fever
 Other: ______________________________
Head, Ears, Eyes, Nose, Throat
 Hearing loss
 Visual loss
Dermatology
 Rashes
 Frequent sore throat
 Unusual birthmarks
Endocrine Glands
 Neck masses
 Decrease of energy
Respiratory
 Shortness of breath
Cardiac
 Dizziness
Gastrointestinal
 Vomiting
 Constipation
 Other: ______________________________
 Easy bruising
 Other: ______________________________
 Cold intolerance
 Other: ______________________________
 Wheezing
 Heart murmur
 Weakness
 Coughing
 Chest pain
 Bloody stools
 Diarrhea
 Other: ______________________________
 Other: ______________________________
 Other: ______________________________
Genitourinary/Reproductive
 Painful urination
 Loss of bladder control
 Other: ______________________________
 Abnormal menstruation  Pregnant
 Menstrual Cramps
Neurological/Musculo-skeletal
 Weakness
 Numbness
 Hyperactivity/ADD
 Headaches
Hem/Onc/Lymphatics
 Abnormal bleeding
 Cancer
 Seizures
 Developmental decay
 Other: _______________________________
 Other: _______________________________
Other Systems/Complaints:______________________________________________________________
______________________________________________________________
Rev. by Elena G. Gozum.M.D./Date