NAME: _______________________________________________________
DATE: __________________
PERSONAL HISTORY
Please Circle
Are your nose or eyes worse if you are near:
(If any, please circle below)
DUST, DOG, CAT, WEATHER CHANGE, GRASS CUTTING, MOLD, SMOKE, FUMES, PERFUMES
YES NO
Do you have a runny nose or wheezing when you take aspirin, Advil or Aleve? (Please circle)
YES NO
Have you taken any of these in the last month: (If any, please circle below)
(1B)
ALLEGRA, CLARITIN, CLARINEX, ZYRTEC, FLONASE, NASONEX, NASACORT RHINOCORT
YES NO
Have you ever taken: (If any, please circle below) (2B)
ALLEGRA, CLARITIN, CLARINEX, ZYRTEC, FLONASE, NASONEX, NASACORT, RHINOCORT
YES NO
What other medications are you taking: _____________________________________________________
Do you have Diabetes, Heart Disease or High Blood Pressure? (If any, circle):
Any other medical problems: ______________________________________________________________
YES NO
Have you had any of the surgeries listed below? (If Yes, please check, give date and name of physician)
YES NO
____ Tonsillectomy
__________ Date
____ Sinus Surgery
__________ Date
____________ Dr. Name ___________ Dr. Name
____ Adnoidectomy
__________ Date
_____ Polypectomy
___________ Date
_________ Dr. Name
__________ Dr. Name
List any other surgeries: _____________________________________________________
Do you have a feather pillow? (79)
YES NO
Do you have a down comforter?
(80)
YES NO
Do you have any pets (3):
YES NO
DOG (46) Dog Stays: Strictly outdoors (54), Indoors, not in bedroom (52), Indoors, allowed in bedroom (53)
CAT (47) Cat Stays: Strictly outdoors (54), Indoors, not in bedroom (52), Indoors, allowed in bedroom (53)
OTHER PETS (Please list) ____________________________________ .
Are you in contact with any indoor pets elsewhere on a weekly basis?
YES NO
Were there previous pets in your house or apartment? (5) If yes, please list ______________________
YES NO
Are you living in a House or Apartment? (1) (Circle which)
YES NO
Do you have a Bedroom carpet, Area rugs, Drapes, Blinds, Shelves or Stuffed Toys in your bedroom?(Circle) YES NO
Do you have a basement? Do you have a damp basement? (Circle which)
Do you have an attic fan?
Do you have a fireplace?
YES NO
(Circle which)
YES NO
Do you have any mold or mildew inside your house or apartment?
Do you have a window air conditioner?
YES NO
Do you use a space or radiator heater?
(Circle which)
Do you have any children under 10-years of age? (113)
How many children? _________
YES NO
YES NO
Ages of children? _________
(114)
Does your child attend: DAY CARE / PRE-SCHOOL KINDERGARTEN? (If Yes, Circle which)
YES NO
Does your job require you to be around young children?
YES NO
Do you teach? If yes, please circle: PRE-SCHOOL / KINDERGARTEN / ELEMENTARY / MIDDLE (111)
Have you ever had an allergic reaction to an insect sting? (9)
YES NO
Type of insect: YELLOW JACKET, WASP, HORNET, HONEY BEE, FIRE ANT, UNKNOWN INSECT (Circle)
Resulting reaction: HIVES, DIFFICULTY BREATHING, SWELLING, WHEEZING, SHOCK (Circle)
Have you ever had an allergic reaction to medication? (10A)
YES NO
Type of medication: PENICILLIN, SULFA, ERYTHROMYCIN, Other _______ - Taken Orally or Shot?
(Circle)
Resulting reaction: HIVES, DIFFICULTY BREATHING, SWELLING, WHEEZING, SHOCK (Circle)
Do you have any family members with asthma or allergies?
MOTHER,
FATHER,
BROTHER,
SISTER,
(33)
CHILDREN,
YES NO
OTHER _________________ (Circle)
Are you exposed to cigarette smoke?
Where: HOME,
WORK (If Yes, Circle which) (32B)
Do you now or have you ever smoked?
Specify (Circle number below and fill in blanks)
1. If Yes - I smoke _____ packs per day, for ______ years. (78)
2. If Yes – I stopped smoking ___ years ago. ___ pack(s) per day for ____ years. (32A)
3.
YES NO
If No - I never smoked.
YES NO