STEPHEN H. KIMURA, M.D.
ALLERGY & ASTHMA
Please complete as accurately and thoroughly as possible.
Relate all answers to your own experience.
Name: _____________________________________________ Nick name: ________________________
Address: ______________________________________________________________ Apt: ___________
City: _____________________________________ State: ____________ Zip: ______________________
Date of birth: ______________________ Social Security # : ____________________________________
Home phone: ________________________________ Cell phone: _______________________________
Emergency contact: _____________________________________ Phone: _________________________
INSURANCE INFORMATION:
Name of primary coverage: ______________________________________________________________
Address: _______________________________City: _______________ State: _______ Zip: ___________
Subscriber Name: ___________________________________ Date of birth: _______________________
Social Security # : ________________________ Employer: _____________________________________
Certificate Number: _____________________________ Group Number: __________________________
Name of secondary coverage: ____________________________________________________________
Address: _______________________________City: _______________ State: _______ Zip: ___________
Subscriber Name: ___________________________________ Date of birth: _______________________
Social Security # : ________________________ Employer: _____________________________________
Certificate Number: _____________________________ Group Number: __________________________
State problems you wish to discuss: ________________________________________________
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List any medical problems you have: _______________________________________________
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List any surgery/dates: __________________________________________________________
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Current medications/doses: ______________________________________________________
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List any drug allergies: ___________________________________________________________
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Any medical problems in your immediate family: _____________________________________
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Marital Status: ______________ Hobbies: __________________________________________
Smoking habits/packs per day: _____________________________ Years: _________________
What type of home do you live in? Apartment / House / Mobile Home
Age of house: ___________________
Type of constructions: Brick / Frame
Air Conditioning: Central / Window / None
Heating: Gas / Electric / Radiator / Other
Humidifier: Yes / No
Mattress: Spring / Foam / Water
Pillow: Foam / Feather / Other
Flooring in bedroom: Carpet / Wood / Tile
Pets:
How many smokers in household: ____________
CIRCLE SYMPTOMS CAUSING YOUR PROBLEM:
General – Nervousness, dizziness, fainting, sinus trouble, frequent colds, fatigue, fever,
Other: ___________________________________________________________
Headache – Where (front, back, right, left), aching, throbbing, sharp, dull, stuffy nose,
Other: ____________________________________________________________
Eyes – Tearing, burning, itching, pain, redness, discharge, puffiness, infections, blurred vision,
Other: ____________________________________________________________
Ears – Pressure, itchiness, drainage, bleeding, infectious, deafness, swelling,
Other: ____________________________________________________________
Nose – Trouble smelling, stuffiness, sniffles, itching, sneezing, snoring, polyps, post-nasal drip,
bleeding, broken nose, surgery,
Other: ____________________________________________________________
Mouth – Itching, tonsillitis, tonsils removed, sore throats, bad breath, swollen lips, trouble
swallowing, mouth breathing, throat clearing, voice change,
Other: ____________________________________________________________
Chest – Shortness of breath, wheeze, pain, tightness, cough, trouble walking, trouble sleeping,
emphysema, bronchitis, pneumonia, tuberculosis, cancer,
Other: ____________________________________________________________
Heart – Pain, hypertension, palpitations, irregular heartbeat, rapid hearbeat,
Other: ____________________________________________________________
Stomach – Vomiting, gas, cramps, belching, diarrhea, blood in stool, worse after foods,
Other: ____________________________________________________________
Menses – Female only – regular, irregular, discharge, itch, cramps,
last menstrual (date):____________
Are you pregnant? Yes / No
Are you taking birth control pills? Yes / No
Kidney – Pain, frequent urination, bladder infections, recurrent infection, itching, chills, fever,
Other: ____________________________________________________________
Joints – Pain, stiffness, swelling, Other: ______________________________________________
Skin – Rash, hives, eczema, blister, itching, swelling, burning, stinging, redness,
Other: ____________________________________________________________
Mood – Anxious, nervous, depressed, Other: _________________________________________
List any other conditions for which you are currently being evaluated or treated: __________
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