This patient history form collects information from a patient visiting an allergy clinic. It includes sections on the patient's reason for visiting, medical history, family history, social history, medications, allergies, and environmental factors. The form is several pages long and collects detailed information to help the doctors assess the patient's condition.

1. Histsend.hcfa 10.17.07 Reviewed form with patient ________
ASTHMA & ALLERGY CARE OF DELAWARE, P.A.
W.J. Geimeier, M.D. R. Kim, M.D. G.V. Marcotte, M.D. Q.C. Nguyen, M.D. A.G. Weinstein, M.D.
Patient History Form - Send Out
Please fill out this form prior to your visit to us and bring it with you to your appointment.
Patient’s name:_________________________________________ Age:________________
Referred by:____________________________________________ Date:_________________
Other doctors to whom reports should be sent:___________________________________________
1. Why are you coming to see us?____________________________________________________________
_________________________________________________________________________________________
2. We will do our best to find out what is causing your problems and help you to feel better by giving you tips to avoid
allergens and irritants and/or how to use medications to treat your symptoms. Besides this, is there anything else you
expect from your visit here?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. If you have respiratory symptoms indicate the pattern:
Head/Nose Chest
Year round, no seasonal variation _____________ _____________
Year round, worse seasonally _____________ _____________
Seasonally only _____________ _____________
If seasonal, list months _____________________________________________________________________________
4. Do you note increased symptoms from any of the following:
a. ALLERGENS b. IRRITANTS
Mowed Grass _____
Dead Grass _____
Dead Leaves _____
Hay _____
Mold _____
House Dust _____
Cats _____
Dogs _____
Feathers _____
Others ___________
Perfumes _____
Soaps _____
Detergents _____
Newspaper
print _____
Smoke _____
Paint _____
Hair Spray _____
Outside Dust _____
Other _____________
c. WEATHER CHANGES d. INGESTANTS
Windy Days _____ Temp. Change ____ Alcohol _____
Cold Fronts _____ Damp weather ____ please list specific ingestants

2. Patient Name:____________________________________________ Page 2
Histsend.hcfa 10.17.07 Reviewed form with patient ________
5. Past Medical History: Please list any medical problem/diagnosis you have (such as glaucoma, cataracts, sinusitis,
nasal polyps, thyroid problems, high blood pressure, heart disease & arrhythmias, gastric reflux (heartburn),
osteoporosis, prostate problems etc.)
1. 5.
2. 6.
3. 7.
4. 8.
6. Please list any hospitalizations or surgeries you have had with approximate dates.
1. 5.
2. 6.
3. 7.
4. 8.
7. Medications: Please list any prescription or over-the-counter medicines, nose sprays, eye drops, herbs, or nutritional
supplements you take daily or occasionally. Please include dosages and frequency (ex: benadryl, 25 mg every 6
hours as needed).
1. 5.
2. 6.
3. 7.
4. 8.
8. Drug Allergies: Are there any medicines you avoid because of allergic or adverse reactions? (please include name of
med, approximate date of reaction, and what the reaction was, ex: penicillin, 1998, hives and shortness of breath).
_____________________________________________________________________________________________
_____________________________________________________________________________________________
9. Are you allergic to any foods? No ___ Yes ___ Please explain:_________________________________________
10. ……. to insect stings? No ___ Yes ___ Please explain:_______________________________________
11. ...…. to latex? No ___ Yes ___ Please explain:_______________________________________

3. Patient Name:____________________________________________ Page 3
Histsend.hcfa 10.17.07 Reviewed form with patient ________
Family History:
12. Is there a family history of allergy?
Type of disease relative(s) affected (mother, brother, etc.)
Hayfever (allergies) _____________________________________________________
Sinus problems _____________________________________________________
Asthma _____________________________________________________
Eczema (atopic dermatitis) _____________________________________________________
Nasal polyps _____________________________________________________
Hives or swelling _____________________________________________________
Food allergy _____________________________________________________
13. Are there any other major medical problems in the family? (Heart disease, diabetes, cancer etc.) _____________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Social History:
14. Have your allergy problems caused you to miss school / work? Y / N How many days per year? _____
15. Smoking __ I have never smoked
__ ex-smoker (When did you quit?______ How long did you smoke?______ How many packs per day?____ )
__ current smoker (How long have you been smoking?___ How many packs per day?____)
16. Do you use drugs or alcohol? ______ How much per day or per week?________________ .
17. What are your hobbies? ______________________________________________________________________
Do any of these make your symptoms worse?___________________________________________________
18. Is there anything at work/ school that makes your symptoms worse? ______________________________________
Children:
19. Up to date on shots? Y / N Height & weight stable? Y / N How many weeks at birth (40?) ___
Adults:
20. Are you  single  married  partnered  separated  divorced  widow(er)?
21. What is your occupation? (If retired, what was your main occupation?) ______________________________
22. Immunizations: last flu shot?___ tetanus/diptheria?___ pneumonia? ____

4. Patient Name:____________________________________________ Page 4
Histsend.hcfa 10.17.07 Reviewed form with patient ________
Environmental Survey
Living Accommodations:
City ____ Apartment ____
Suburbs ____ House ____
Country ____ Trailer ____
Present address for ________ years
Basement and/or crawl space: None: ____
Dry ____ Damp ____
Does your home have any damp or musty areas?
None ___ Basement ____ Family room ____
Bedroom ____ Bathroom ____ Kitchen ____
Furniture:
Wood, vinyl or leather _____
Upholstered/stuffed ____
Carpet:
Wall to wall ____ Area ____
Bedroom:
Carpet:
Wall to wall ____ Area____
Mattress:
Age ____ Rubber ____
Regular ____ Water ____
Pillow:
Feather ____ Rubber/synth. ____
Blanket:
Wool ____ Cotton/synth. ____
Comforter/Afghan:
Down ___ Polyester/synth.___ Wool ____
Window Coverings:
Curtains ____ Shades ____ Blinds ____
Allergy proof covers ? None ____
Pillows ___ Mattress ___ Box Spring ___
Dust Collectors: Wall hangings ___ Stuffed animals ___
Books ___
Climate Control:
Fuel:
Gas ____ Oil ____ Electric____ Wood ____
Home Heating:
Hot water/steam/radiator _____ Forced hot air_____
Electric baseboard _____ Kerosine Heater _____
Furnace Filter: Change_____ x a year
fiberglass ___ aluminum ___ electrostatic ___ HEPA ___
Air Purifiers: None ____ Yes____
Where?_____________________________
What type? _________________________
Dehumidifiers: None____ Yes____
Where? __________________________
Humidifier: None ____
Central________ Portable Unit_________
Where? ____________________________
Air Conditioning: None ____ Central ____
Unit (which rooms?)________
House plants: None ____
Livingroom, how many? ________
Bedroom, how many? ________
Other:
Animal Contact: None ____
Indoor Outdoor
Dog _________ _________
Cat _________ _________
Bird _________ _________
Mice _________ Horse ________
Other ________ _________
Have you ever noticed cockroaches or waterbugs
at home?Yes ____ No ____
at work/school? Yes ____ No ____
Smoking:
How many smokers are there in the house? _____
Who smokes? ___________________________