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Dr. A. Best
Anywhere, USA
Phone, Email, Fax
Initial Visit
Name:
DOB:
Age:
Sex Male/ Female
Date:
Patient:
Usual Physician:
Referred by:
CC:
THE MAIN PROBLEMS FOR COMING HERE ARE:
Yes/No
Itchy or watery eyesNasal Congestion or runny noseSneezingSnoring or breathing thought the mouthDrainage down the throatFrequent yellow or green nasal drainageDo you have asthma?Diagnosis of asthma made ____ yrs agoCoughingWheezing or shortness of breathNumber nights wheezing/ coughing per week___
Number nights wheezing/coughing per month___
Number of past hospitalizations for asthma___
Number of past emergency visits for asthma___
Days of school or work missed in past year___
Possible reaction to food or drug___
Bee sting reactionsRashesFrequent infectionsNumber of ear infections in the past year___
Number of sinus infections in the past year___
Number of pneumonias during lifetime___
HeadachesVomiting/DiarrheaAbdominal PainOther (explain)THESE SYMPTOMS OCCUR:
Spring [ ] Summer [ ] Fall [ ] Winter [ ]
Days or weeks at a time [ ] All the time? [ ]
At home [ ] Which room? ________________
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Physician Notes:
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SYMPTOMS GET WORSE OR IMPROVE
Outdoors [ ]
Indoors [ ] At work or school [ ]
All day [ ] Night or morning [ ]
Patient’s Name: ________________________________________
SYMPTOMS ARE MADE WORSE BY:
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] Colds/Infection
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] Cigarette smoke
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] Mowing grass
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] Raking leaves
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] Perfumes or scents [
] Dusting or cleaning [
] Food
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] Cats/Dogs
] Weather changes
] Windy days
] Damp areas
] Heat
] Cold
] Other
ALL CURRENT MEDICINES number mg, tab, caps, or inhaler puffs
___________________________________ ___________ ________ Times per day
___________________________________ ___________ ________ Times per day
___________________________________ ___________ ________ Times per day
___________________________________ ___________ ________ Times per day
___________________________________ ___________ ________ Times per day
PREVIOUS ALLERGY OR ASTHMA MEDICATIONS(INCL. OTC):
____________________ [ ] helped [ ] no help [ ] drowsy [ ] jittery
____________________ [ ] helped [ ] no help [ ] drowsy [ ] jittery
____________________ [ ] helped [ ] no help [ ] drowsy [ ] jittery
CURRENT ENVIRONMENT (X IF PRESENT):
Home/Apt ______________ Length of occupancy ____________
How old is the building? ________ Yrs
Yes/No
Yes/No
Cats
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Dogs
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Birds
Air conditioning
  Humidifier
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Other pets
  Lots of houseplants
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Feather pillows
  Damp baseball
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Down comforter
  Mold growth
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Carpets or rugs
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Air cleaner
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Cigarette smoke
Improvements on trips
PAST ALLERGY HISTORY: (Use space at right if needed)
Yes/No
Previous allergy testing?
If yes then answer the questions below:
Testing done by Dr. ____________ in 19 __
Previous allergy shots
Still on allergy shots
Shots are received every ____ week now
Allergy shots helped
Only minor reaction with the shots
If major reactions then explain:
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PAST MEDICAL HISTORY
Hospitilizations: Age or
Year
____ for ________________________________
____ for ________________________________
____ for ________________________________
Surgeries:
____ for ________________________________
____ for ________________________________
____ for ________________________________
Emergency Visits:
____ Times in past year
____ Times in past five years
Drug Allergies:
Symptoms:
_________________Caused_______________________________
_________________Caused_______________________________
_________________Caused_______________________________
Immunizations up to date for the age: Y[ ] N [ ]
Immunization Adverse Reactions:
_________________Caused_______________________________
Other Chronic Health Conditions:
Age or
Year
___________________________Since______
___________________________Since______
___________________________Since______
Notes:
Family History
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Allergies Asthma Freq. coughing Freq. Infections
Father
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Mother
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Brother(s)
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Sister(s)
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Grandfather(s)
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Uncle(s)
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Aunt(s)
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Cousin(s)
Other chronic conditions such as cystic fibrosis, emphysema,
recurrent hives or swelling, lupus, rheumatoid arthritis, etc.;
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Patient’s Name: ________________________________________
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Social History
Primary Residence for the patient is:
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One Home
Split between homes
Current occupation is: ________________________________
Occupational exposures: ______________________________
__________________________________________________
Smoking: Y [ ] N [ ] If yes, years____ packs/day____
Use of Recreational Drugs
Smoked_______ Intranasal_______ Other________
Drink Alcohol? Y [ ] N [ ]
Number of drinks per day_____
Other relevant social factors:___________________________
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Review of Systems: (check if present)
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Fever
Weight loss
Skin problems besides eczema
Joint swelling or pain
Blood count problems (anemia, ect.)
Eye problems
Throat infections
Heart problems, high blood pressure or palpitation
Stomach upset
Urinary or bladder problems
Nerve or psychiatric problems
Hormone problems (such as hot flashes, etc.)
Other Comments:
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Name of person filling out this history form (please print): _____________________________________________
Relationship if not the patient: ___________________________________________________________________