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