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Medical History Form
Questions that are in BOLD and display (Required) are required
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Office Location:
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*Last Name (Required)
*First Name (Required)
Middle Initial |
*Date of Birth
*Gender (Required)
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Primary Care Physician
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*Please describe the problem for which you are seeking attention: (Required)
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For how long has it been occurring?
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What makes it worse or better?
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Is it worse with any particular seasons?
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If so, which ones?
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Does your condition affect school/work performance; athletic performance; social activities?
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*What medications have you tried for this problem? (Required)
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Have they worked?
If so, which ones?
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*Do you currently have or have you ever been diagnosed with asthma? (Required)
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Dates Diagnosed:
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How many bursts of oral steroids (prednisone) have you had in the past 12 months?
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How often do you use your rescue inhaler (albuterol, Proventil)?
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DESCRIPTION OF ALLERGIC CONDITIONS: |
| *Are you allergic to pollens, foods, or certain medicines? (Required)
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If so, which ones?
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| Please check all of the following for which you are experiencing a problem. Describe the problem as appropriate:
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Which of the following factors contribute to your problem?
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Change in:
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| Weather
Heat
Cold
Increased humidity
Dust
Leaves
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| Freshly mown grass
Hay
Attics
Animals
Perfumes
Odors
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| Soaps
Chemicals
Cold drinks
Alcohol (Beer/Wine)
Exercise
Other
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Do symptoms occur after eating?
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If so which of the following food types contribute to your problem?
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Milk
Eggs
Peanut
Wheat
Fish
Shellfish
Nuts
Other |
MEDICAL HISTORY |
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Which of the following other medical conditions have you been treated for in your lifetime?
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Diabetes
High blood pressure
Thyroid problems
Cancer
Stroke
Hives/Angioedema
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Stomach problems (i.e reflux)
Emphysema
Arthritis
Pneumonia
Eczema
Cystic Fibrosis
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Other |
If any of the medical conditions above are checked, please provide specifics--diagnosis; dates; current prognosis
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Have you had any surgeries?
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If so what type and when?
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Have you had any hospitalizations?
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If so for what reason?
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Do you have a history of:
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| Asthma
Hayfever
Hives
Sinusitis
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Which of the following medical conditions run in your family? Please describe below.
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| Diabetes
High Blood Pressure
Thyroid problems
Cancer
Stroke
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| Stomach problems
Emphysema
Arthritis
Pneumonia
Asthma
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| Cystic Fibrosis
Eczema
Hives/Angioedema
Other
Allergies
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If any medical conditions above are checked, please provide specifics--relation to you; diagnosis; dates; current prognosis:
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MEDICATIONS |
*What prescription medications (other than those noted above) are you taking; what purpose; under whose direction; and what are their doses? (Required)
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*What over-the-counter medications do you take? Be sure to include vitamins,
pain medicines (aspirin; tylenol; ibuprofen; etc.); herbal medicines; etc.
Indicate frequency and reason you are taking the medication. (Required)
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ENVIRONMENT |
What type of home do you live in?
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How long have you lived there? |
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How old is your home? |
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Please check which of the following pertains to your home:
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| Housing Type: |
| House
Apartment
Trailer
Condominium
Other
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| Type of Heating: |
| Central
Radiator
Forced Air
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| Type of Space heater: |
| Electric/Heat Pump
Gas
Oil
Floor Furnace
Wood stove
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Air Conditioning:
Central
Window Units
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| Type of Foundation |
| Basement
Crawl space
Concrete slab
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| Type of Flooring
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| Generally, throughout the house |
| Hardwood
Tile/sheet vinyl
Carpet
Approximate age: |
| In your bedroom |
| Hardwood
Tile/sheet vinyl
Carpet
Approximate age: |
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On what floor is your bedroom? |
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Do you use zippered covers on your pillows?
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Mattress?
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PETS AND OTHER ANIMALS |
| Dog
How long have you had your dog?
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| Cat
How long have you had your cat?
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Other type of pet?
Describe:
How long have you had this pet ?
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| Farm Animals
Describe: |
PERSONAL INFORMATION |
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Do you or did you ever smoke cigarettes?
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Cigars
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Other--Describe
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How long have you smoked?
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If you smoked but quit, how long ago did you quit?
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What is your occupation?
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Do your symptoms worsen while at work?
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If so how? |
FOR CHILDREN |
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Birth weight |
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Did your child have any problems at birth?
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Please describe
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Is/was your child breastfed?
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If so, for how long? |
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Does your child have a food intolerance?
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If yes, to what foods? |
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Does your child have and activity related breathing problems?
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If yes, please describe
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Does your child wake at night with breathing problems?
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In what grade at school is your child? |
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How much school was missed last year for illness? |
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Does your child's classroom have: Carpeting?
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Air conditioning?
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Pets?
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Does your child have cigarette smoke exposure?
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Please list your child's sibling(s) and any health problems they have:
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