Upper Respiratory Tract (Nose, Sinus, Ear, and Eye) Problems



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Colorado Allergy and Asthma Centers, P.C. New Patient History Complete the following information. Please put an X in each box that relates to your problems. Use additional page to answer any questions if more room is needed. Patient Name: Date of Birth: Date of First Visit: (Please Print) Were you referred by a physician or other provider? o no o yes If yes, who Briefly state what problems are bringing you here: Upper Respiratory Tract (Nose, Sinus, Ear, and Eye) Problems Note: If No UPPER Respiratory Tract problems, Check Here And Go To Page 2 Lower Respiratory Tract. When did these symptoms first begin? o sneezing o itching nose o runny nose o nasal congestion o stuffiness o post-nasal drip o decreased or absent sense of smell o nose bleeds o snoring o nasal polyps; if so: o past o present o drainage cough o itchy throat o sore throat o bad breath o frequent colds; if so, how many per year? 1-5 o 5-10 o o headaches/sinus pain o recurrent ear infections o ear plugging/ popping/ fullness o hearing loss o dizziness o septum deviated o septum perforated o previous nasal or sinus surgery o recurrent or chronic sinus infections; if so, how many per year? o 0-4 o over 4 o sinus x-rays or sinus CT scan done if so, when? result o normal o abnormal o ENT evaluation; if so, when? name of doctor: Eyes: o itch o red o watering o swollen lids o dark circles o fatigue/ tired o poor concentration o other: Symptoms Caused Or Aggravated By: o cold air o weather o odors / scents / fragrance o tobacco smoke o dusting / vacuuming o musty odors / mold o yard work / pollens o being outdoors o aspirin / related medications o animals, list: o other: Year-round symptoms? o yes o no Season(s) in which symptoms are worst: ( X all that apply) o spring o summer o fall o winter Symptoms worse: o AM o PM o night Symptoms interfere with: o sleep o exercise / activity o missed school o missed work Symptoms are: o improving o worsening o unchanged 1 List medications tried for nose/sinus symptoms (include prescription and over-the-counter oral medications and nasal sprays): Current Medication Does it work? Past Medication Did it work? o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no Office Use Only 9/10 (Form #105)

Name_ Lower Respiratory Tract (Chest, Lung) Problems Note: If No LOWER Respiratory Tract Problems, Check Here And Go To Page 3. When did chest symptoms first begin? o chronic or recurrent cough o coughing spells o dry o loose; is mucus coughed up? o yes o no if yes, is mucus colored? o coughing up blood o wheezing; when breathing o out o in o chest tightness or pressure o throat tightness o shortness of breath o difficulty taking a full breath o cough or breathing problems interfer with sleep o asthma diagnosed by a physician? Age: o emergency room visit(s) for asthma; how many? o hospitalized for asthma; how many? o intensive care unit for asthma o oral steroids (Prednisone, Medrol, Prednisolone) taken for asthma if so, number of times taken per year: o 1 o 2-3 o greater than 3 date of last use: Symptoms Caused Or Aggravated By: o colds / upper respiratory infections o sinus infections o exertion / exercise; type: o cold air o weather change o odors / scents / fragrance o tobacco smoke o eating / drinking o heartburn / acid reflux o emotional stress / anger o laughing / crying / cough o your workplace or school o aspirin / related medications o dusting / vacuuming o musty odors / mold o yard work / pollens o being outdoors o animals, list: o other: o history of recurrent bronchitis o history of recurrent pneumonia o history of recurrent croup o previous chest x-ray or chest CT scan; if so, when? result: o normal o abnormal o peak flow meter used; if so, best reading: o pulmonary function (lung) test: o yes o no o pulmonary (lung specialist) evaluation; when: specialist s name: o Are you physically active on a regular basis (formal exercise, play sports, other types of physical activity)? o yes o no o Do you experience a cough, wheeze, difficulty breathing during exercise/physical activity? o yes o no o other symptoms (list): Year-round symptoms? o yes o no Season(s) in which symptoms are worst: ( X all that apply) o spring o summer o fall o winter Symptoms interfere with: o sleep o missed school o exercise / activity o missed work Symptoms are: o improving o worsening o unchanged 2 List medications tried for lower respiratory symptoms (include prescription and over-the-counter oral, inhaled, and injected medications): Albuterol o inhaler o nebulizer How often used? Current Medication Does it work? Past Medication Did it work? o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no o yes o no _ o yes o no Office Use Only _

Name: Skin Problems Note: If No SKIN Problems, Check Here And Go To Previous Allergy Evaluation below. Skin Symptoms: o eczema o rash When did skin/eczema symptoms first begin? o itching o excessively dry, scaly skin o irritated red patches o weepy, oozing rash o recurrent skin infections o other skin symptoms (list): Location of eczema/rash/hives: o arms o legs o trunk o head o neck Frequency of above symptoms: o daily times per week times per month o other: Do skin symptoms occur year-round? o yes o no Season(s) in which above skin symptoms are worst: o spring o summer o fall o winter Has a physician diagnosed your rash? o yes o no if yes, what was the diagnosis? o hives o eczema o contact dermatitis o other: Have you seen a dermatologist for your skin problems? o yes o no if yes, name of doctor: when seen: List everything that causes or aggravates your skin symptoms: List medications tried for above symptoms (include prescription and over-the-counter oral medications, creams, and ointments): Current Medication Does it work? Past Medication Did it work? o yes o no o yes o no o yes o no o yes o no o yes o no o yes o no o yes o no o yes o no Previous Allergy Evaluation(s): o no o yes Date(s): Skin testing: o no o yes Blood testing for allergy: o no o yes Were you allergic? o no o yes if allergic, was it to: o animals o dust / mites o pollen o mold o food o other (list): Allergist: Name: o welts/hives o skin swelling When did hives/swelling first begin? o itching o face swelling o hand/foot swelling o lip swelling o tongue /throat swelling o difficulty breathing from swelling State: Previous allergy injection(s): o no o yes If yes, age or date(s) of treatment: If yes, how long did you take shots? o 6 month o 1 year o 2 years o 3 years o longer were allergy injections effective? o no o yes o not sure adverse reactions to allergy injection(s)? o no o yes If yes, list: 3 Office Use Only

Name: Insect Sting Reactions: o no o yes If yes, insect(s) causing reaction: _ symptoms: o large swelling at site o hives o breathing problems o dizzy / lightheaded o other (list): age or date when occured? (Epi-Pen ) Epinephrine/ Adrenalin device prescribed? o no o yes Drug Allergies / Intolerances: o no o yes When Did Reaction Occur? Is The Medication Name Or Type Of Medication Reaction(s) Noted Age or Date Completely Avoided? o yes o no o yes o no o yes o no o yes o no Food Allergies / Intolerances: o no o yes When Did Reaction Occur? Is The Food Food Reaction(s) Noted Age or Date Completely Avoided? o yes o no o yes o no o yes o no o yes o no Latex or Rubber Allergies / Intolerances: o no o yes If yes, explain: Past Medical History: Flu vaccine: o no o yes Pneumonia vaccine: o no o yes T.B. test: o no o yes result: o positive o negative Birth history (if patient is a child): o normal o premature o problems at birth: Hospitalization(s): o none Surgery(s): o none Serious injury(s): o none Other medical problems: All Current Medications not already listed (Include Over-The-Counter and Supplements. Use additional page if necessary.) Medication Dosage Frequency (how often) Medication Dosage Frequency (how often) 4 Family History: Do any close family members have the following? Check the appropriate box below: (even if mild or outgrown) Father Mother Brothers Sisters Children Other diseases that run in the family: Hay fever / Allergies o o o o o Immune problems o yes o no Asthma o o o o o Family member: Eczema o o o o o Cystic Fibrosis o yes o no Sinus trouble o o o o o Family member: Migraine headache o o o o o Emphysema o yes o no Family member:

Name: Social History: Has the patient ever smoked? o no o yes If yes, for how many years: Current smoker? o yes o no If no, when did you quit: how much do/did patient smoke? Number of packs per day o less than 1/2 o 1/2 o 1 o 2 or more Alcoholic beverages? o no o yes If yes, how often: Marijuana or other recreational drugs? o no o yes If yes, how often: 5 Review of Systems: (check all that applies) General Gastrointestinal o Good general health o Difficulty swallowing* o Weight gain; past year: lbs. o Heartburn / acid indigestion / reflux o Weight loss: lbs. stomach acid coming up* dieting o yes o no frequency: treatment: o Excessive tiredness o History of ulcer o Excessive thirst / drinking o Frequent spitting up or wet burps (infants) o Recurrent fever o Hiatal hernia o Recurrent night sweats o Recurrent vomiting o Pregnant o Frequent diarrhea o Planning pregnancy within year o Bloody or black stools o Cancer history type: o Constipation o Liver disease: o History of Hepatitis Eyes o Dry eyes o Wear contact lenses o Cataracts o Glaucoma Mouth / Throat o Excess dryness of mouth o Excessive throat mucus* o Throat clearing* o Hoarseness or voice problems* o Sensation of something stuck in throat* Heart o Palpitation or pounding of heart o Irregular heart beat o Angina / chest pain / tightness o History of heart attack o Thrombophlebitis / blood clots o Swollen ankles / feet o Heart murmurs o High blood pressure Hepatitis Type: o A o B o C if so, when diagnosed o Other problems: o GI specialist: when: Genitourinary o Frequent urination o Kidney trouble o Bladder infection o Prostate problem (men) o Kidney stones Musculoskeletal o Painful or stiff joints o Swollen joints o Rheumatoid Arthritis o Osteoarthritis (age / injury related) o Osteoporosis o Osteopenia o Bone Density Test date: Endocrine o Thyroid gland problems o Adrenal gland problems o Diabetes o Parathyroid disease Neurologic o Sinus headache o Migraine headache o Tension headache o Hyperactivity / ADD / ADHD o Dizzy spells o Fainting spells o Convulsions / epilepsy / seizures o Sleep Apnea o Insomnia o Depression o Anxiety o Ever see a psychiatrist / psychologist? o Currently see one Blood / Lymphatic o Blood disorder: o Anemia o Bruise easily o Swollen lymph nodes o Previous blood transfusion o Risk factors for AIDS o Testing for HIV if so, result: o positive o negative o Other symptoms or medical problems (list) ROS reviewed with patient/parent MD/PA Initials

Name: Environmental History How long has patient lived in Colorado? What other states/countries has patient lived in? Primary Home (for patient living in two homes, also complete Second Home below) Type: o house o townhouse o condominium o apartment o mobile home o other: Age of home: o less than 10 years o 10-20 years o 20-50 years o over 50 years Length of time in home: Construction Basement: o none o finished o unfinished o walkout o dirt o crawl space o moisture problem Heating and Cooling Heat: o forced air heat o hot water or radiant heat o electric heat o woodburning stove o Fireplace; o wood o gas Cooling system: o none o central air o window air conditioner o swamp cooler o attic fan Central filter type: o none o fiberglass o HEPA o electrostatic Frequency of filter change or cleaning: Room air filter: o none o HEPA o electrostatic o ion generator o other: which room Air Ducts cleaned: o no o yes If yes, when Mold and Moisture Humidifier: o none o furnace o cold-mist o ultrasonic o steam Water leak(s): o none o past o current o musty odor o visible mold Cleaning Frequency of dusting: o daily o 2-3 times per week o 1 time per week o every 2 weeks o less often Frequency of vacuuming: o daily o 2-3 times per week o 1 time per week o every 2 weeks o less often Patient s Bedroom Flooring: o carpet o wood o tile o linoleum o area rug Bed: Mattress: o innerspring o foam o waterbed o bunk o futon Pillow: o feather (down) o foam o synthetic Pets o no o yes Sleep in Number How Long Owned? Type / Breed Outside Inside Bedroom o Dog(s) o o o o Cat(s) o o o o Other(s) o o o Smokers (at your home) o No one o patient o mother o father o husband o wife o other Other Environments Daycare: Number of days per week o Animals Number in room Relatives Homes: Number of days per week o Animals o Smokers School /Work: Number of days per week o Animals o Smokers Hobbies / Interests Occupation / School / Daycare Type of work / school / daycare: Kinds of materials exposed to at work / school: Second Home (for patient living in two homes, please complete the following): Time spent in second home: Smokers: Pets: Other exposures: 6 I have reviewed page 1-6 with parent/patient. Physician / PA Signature Date

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