NEW PATIENT ASTHMA/ALLERGY
Past Medical History
Date
Comment
Past Surgical
History/Hospitalizations
Date
Comments
Medications
Allergies
FAMILY HISTORY
Problem
Relation
Name
Comments
Social History
Tobacco Use
Alcohol Use
Drug Use
Y/N
Marital
Status
S/M/D/W
Y/N
Spouse
Name
Y/N
# of children
Sexual
Activity
Y/N
Years of
Education
Occupation
ADULT
Environmental History
Type of home
Type of
Heating and
cooling
Where is the
carpet in the
home
Pets
Smokers in
house
Allergy Proof
bed
Pillow type
House
Central
Bedroom
Dog
Yes
Yes
Cotton
Apartment
Window unit
Whole house
Cat
No
no
Feather
Condo
Living space
Bird
Modular Home
none
Reptile
Mouse
Rat
None
Foam
Review of System
Eyes itching
Eyes discharge
Eyes Redness
Eyes Swelling
Glasses/Contacts
Ear pain
Ear Drainage
Ear Swelling
Ear Infection
Nasal Congestion
Nose Bleeds
Nasal itching
Drainage
Yes
Y
Y
Clear
Colored
Y
Y
Y
Y
Y
Clear
Colored
Y
Y
Y
Clear
Colored
Y
Y
Clear Colored Y
N
Nasal
Sneezing
Headaches
Sore Throat
Throat swelling
Throat redness
Hoarseness
Throat Itching
Tongue Swelling
Chest Pain
Palpitations
High Blood Pressure
Swelling in hands or feet
Difficulty Lying flat
Cough
Sputum/Mucous
Wheezing
Shortness of Breath
Chest Tightness
Change in appetite
Nausea
Vomiting
Indigestion
Sour Taste
Diarrhea
Constipation
Acne
Hives
Skin Itching
Skin Dryness
Skin Redness
Moles
Rash
Scaly skin
Diabetes
Thyroid problems
Cold or heat intolerance
Excessive Thirst
Fever/Chills/Sweats/Diarrhea/Fatigue/Weight
loss
Y
No
N
N
N
N
N
N
N
N
N
N
N
N
Clear Colored
Comments
Y
N
Throat
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Clear
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Colored
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
If yes, please
circle