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1 North Country Allergy & Immunology Associates Specialists in Asthma, Allergy, and Immunology 531 Washington Street, Suite 4122 Watertown, NY Northcountryallergy.com John D. Cosachov, D.O. Telephone (315) Board Certified in Allergy & Clinical Immunology Fax (315) Single Married NAME: Divorced Birth Date Widow (er) Male/Female Child Spouse/Domestic Partner s Name Address Phone Number: Work Number: Cell Number: Parents Name (if you are a minor): Parents Address (if different from above): Referring Physician: Family Physician Medical Health Insurance Plan How did you hear about us? _ Yellow Pages? YES Heard about via a friend (Name) A. SOME OF THE FOLLOWING SYMPTOMS ARE COMMONLY SEEN IN ALLERGIC DISORDERS. PLEASE CIRCLE ALL THAT YOU EXPERIENCE EITHER OCCASIONALLY OR REGULARLY. (Office Only) EYES ITCHING INFLAMATION TEARING BLURRING OF VISION DARK CIRCLES BENEATH THE EYES NOSE - ITCHING SNEEZING CONGESTION NASAL DRAINAGE MOUTH BREATHING SNORING (CLEAR/YELLOW) DECREASE IN SENSE OF SMELL POLYPS SINUSES - PAIN PRESSURE SENSATION HEADACHE OVER SINUS AREAS TREATED FOR SINUS INFECTIONS? HOW MANY? THROAT- ITCHING POSTNASAL DRAINAGE HOARSENESS THROAT AND MOUTH ULCERS THROAT CLEARING EARS - ITCHING BLOCKING FULLNESS HEARING LOSS DIZZINESS DRAINAGE EAR PAIN POPPING NOISES CHEST - COUGHING WHEEZING SHORTNESS OF BREATH EXCESSIVE MUCOUS (CLEAR, COLORED) BLOODY MUCOUS CHEST PAIN HISTORY OF PNEUMONIA HEADACHES OVER EYES OVER CHEEKS NECK/BACK OF SKULL VISUAL PROBLEMS RELATED TO MENSES MIGRAINE TYPE GASTROINTESTINAL - NAUSEA VOMITING DIARRHEA EXCESSIVE GAS/BLOATING HEARTBURN/INDIGESTION ABDOMINAL PAIN RECTAL BLEEDING DIFFICULTY SWALLOWING SKIN -HIVES ITCHING ECZEMA PSORIASIS SUN RELATED RASHES

2 Page 2 B. ARE THE SYMPTOMS RELATING TO YOUR NOSE, SINUSES, EYES, AND BRONCHIAL AREAS PRESENT: 1. THROUGHOUT THE YEAR... YES... NO 2. INCREASED IN SPRING, SUMMER FALL OR WINTER MONTHS... YES... NO (Circle seasons applicable) 3. INCREASED AT SCHOOL/WORK... YES... NO 4. MORE SEVERE OUTDOORS... YES... NO C. CIRCLE ANY OF THE FOLLOWING WHICH CAUSE OR INCREASE SYMPTOMS: DUST COSMETICS PERFUMES EXCITEMENT ANIMALS (WHAT KIND) GRASS AIR CONDITION EXERTION FEATHERS WEEDS PAINTS, VARNISH INFECTION TOBACCO, CIGARETTE SMOKE TREES INDUSTRIAL FUMES WORRY, TENSION DAMPNESS RAIN FLOWERS SOAPS, DETERGENTS LAUGHING TEMPERATURE CHANGE HAY FOOD ODORS MENSES ASPIRIN RAKING LEAVES EXCESSIVE HEAT COLD AIR LATEX RUBBER GLOVES PAST ALLERGY HISTORY D. PREVIOUS ALLERGY TESTING: YES NO If yes, please answer the following questions: Testing by Dr. in Did you receive allergy injection treatment? YES NO Are you still receiving this treatment? YES NO If yes, how often? Was this treatment helpful? YES NO (Office Only) E. Have you experienced any severe reactions to a bee sting or other insect bites? If yes, describe F. Are there any foods that give you discomfort or that you cannot eat? If yes, please describe: G. Are there any medications you cannot tolerate or are allergic to? H. Please list ALL medications you are currently using for allergies, asthma or any other medical problems, including dosage and frequency Medications used in the past for allergies and asthma. SOCIAL HISTORY I. If patient is a minor: A. Parents - Married Divorced/Separated B. If divorced/separated patient living in only one household or dividing time in both households?

3 Page 3 J. HOME ENVIRONMENT Please circle (Office only) 1. House Apartment Rural Urban 2. Heating - Forced Air Steam Radiators Hot Water Baseboard Electric Wood Stove Fireplace Kerosene Space Heater 3. Fuel - Gas Electric Oil Coal Wood 4. Dust Filter Furnace Room 5. Humidifier- Furnace Room 6. Dehumidifier - YES NO 7. Air Conditioning - YES NO 8. Basement - Dry Damp Recreation Area 9. Bedroom A. Floor Wood Tile Wall-to-wall Carpeting room size rug Throw rugs B. Rug Pad Foam Synthetic C. Mattress - Coil spring, Water, Foam, Other D. Pillows Foam, Feather, Synthetic E. Blankets Electric Wool Synthetic Down 10. Many Plants at home? YES NO K. Animal or bird contact in your home or other homes (Circle) Cat Dog Gerbils Guinea Pig Parrot Parakeet Cattle Horses Chickens Pigeons L. OCCUPATIONAL HISTORY: A. Present Occupation: B. Are there irritating fumes, dust, odors, or other respiratory irritants in the work environment? YES NO Please describe M. Do you currently smoke: YES NO How Much? How Many years? Did you use tobacco in the past: YES NO When did you quit? Is there tobacco smoke exposure in the home from other individuals? YES NO N. Do you use any recreational drugs? YES NO O. Do you drink alcoholic beverages? YES NO If so, frequency and quantity P. List your hobbies, if any Q. Birth History (if patient is a child): Type of Delivery Full term or premature Complications? R. PAST MEDICAL HISTORY High Blood Pressure Thyroid trouble Heart Disease Stomach hernia (Hiatal Hernia) Diabetes Ear Infections Anemia Nervous Breakdown Tuberculosis Nasal Polyps Stomach Ulcer Congenital Problem/What? Diverticulitis Glaucoma Migraine Heart Murmur Asthma Chicken Pox Other Medical Problems, Please list S. Hospitalizations: Age or year Surgeries Emergency Visits X-ray Exams Chest, Sinus, Other Any recent Blood work? Childhood Immunization? Pneumovax Flu Tetanus

4 Page 4 T. FAMILY HISTORY: Allergies Asthma Living Deceased Cause of Death Physician Notes Father Mother Brother(s) Sister (s) Grandfather Grandmother Other U. REVIEW OF GENERAL HEALTH CONDITION (CIRCLE) General: A. Weight loss Weight gain Weakness Fever Chills Fatigue Sweating at night (Office only) Skin: B. Skin disorders ENT: C. Nasal polyps Nose bleeding Eye: D. Loss of vision chronic inflammation Cardio/Pulmonary E. Hypertension Chest pain History of rheumatic fever Heart murmurs Ankle Swelling Shortness of breath w/exertion GI: F. Difficulty in swallowing Blood in stools Abdominal pain History of jaundice Recurrent diarrhea GU: G. Burning on urination Blood in urine Incontinence Difficulty urinating GYN: H. Menstrual problems Abnormal pap smears RHEU: I. Arthritis Muscle pain Muscle weakness HEM: J. Anemia Easy bruising Swollen glands NEURO: K. Depression Fainting spells, Memory difficulty Sleeping difficulty Drug dependency Alcohol dependency Emotional problems Seizures ENDOCRINE: L. Hormonal irregularities Menopause V. Is this office treating another family member? YES NO If yes, name and relationship: If the doctor could help you with the one thing bothering you the most, what would it be? W. Name of person completing history form Relationship SIGNATURE

5 North Country Allergy & Immunology Associates Specialists in Asthma, Allergy, and Immunology 531 Washington Street, Suite 4122 Watertown, NY John D. Cosachov, D.O. Telephone (315) Board Certified in Allergy & Clinical Immunology Fax (315) PATIENT INSURANCE INFORMATION (please bring your cards) Primary Medical Insurance ID/SSN# Policy Holder DOB Relationship Employer Secondary Medical Insurance ID# Policyholder DOB Relationship Military Members (If the info below is not filled out we will not be able to schedule your appointment): Direct Supervisor: Supervisor s Phone #: Unit: _ Unit Phone #:

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in