ALLERGY & ASTHMA SPECIALISTS PC
www.njallergydoctors.com
Leonard Silverstein, MD
Ruth LK Gold, MD
Jennifer Sherman, DO
Niya Wanich, MD
Health Questionnaire
Patient:
D.O.B.:
/
Height:
/
Age:
DATE:
/
/
Weight:
Reason for visit:
Medications:
Name
Strength
(e.g., 10 mg.)
Name
Strength
(e.g., 10 mg.)
Please list the name
and strength of the
medications you are
currently taking. (For
example, Digoxin
0.125 mg.)
Drug Allergies:
Drug
Reaction
Drug
Reaction
Please list any drug
allergies, including
reactions. Please state
NONE if no allergies.
Non-Drug Allergies:
Substance
Reaction
Substance
Reaction
Name
Helped? Y/N
Name
Helped? Y/N
Please list any food or
non-drug allergies,
including reactions.
State NONE if no
allergies. (For
example, latex, mold,
milk, nuts, etc.)
OTC Antihistamines:
Please list the name of
any over-the-counter
antihistamines you
have tried and
whether they have
helped you.
Past Illnesses
Asthma
Broken Nose
Bronchitis
Croup
Deviate Septum
Eczema
Please check the box if you have had any of these illnesses in the past.
Emphysema
Food Allergy
Frequent Headaches
Hay Fever
Heart Disease
High Blood Pressure
High Blood Cholesterol
Hives
Hormonal Difficulty
Migraine
Nasal Polyps
Nasal Surgery
Overactive Thyroid
Prematurity
Resp. Support at Birth
Seasonal Allergies
Sinus Disease
Skin
Stomach Disease
Underactive Thyroid
Cancer
______________________________________________________________________
Please describe type of cancer and treatment you have received. (For Example, radiation, chemotherapy, surgery)
Other
____________________________________________________________________________________________
Previous Surgeries
Please put the date of any of the following past surgeries
(MM/YYYY)
Surgery
Month/Year
Adenoidectomy
Please list and date any additional previous surgeries.
Surgery
Month/Year
Ear (PE) tubes
Septoplasty
Sinus Surgery
Tonsils and Adenoids
Family History
Please check if any blood relative has suffered any of the following:
Asthma
Drug Allergy
Eczema
Food Allergy
Frequent Headaches
Seasonal Allergies
Cancer
Diabetes
Heart Attack
High Cholesterol
Hypertension
Kidney Problems
Obesity
Osteoporosis
Respiratory Problems
Stroke
Social History
Pets
None
Cat
 Dog
Past
Bird
Rodent
Other:
Currently
How long has family had a pet?
Is/Are this/these pet(s) allowed in the patient’s bedroom?
Yes
Housing
Dwelling
City
Suburbs
Rural
House
How long has the patient lived at this residence?
Bedding
No
_____Months
Apartment
OR
Condo
______Years
(What type of bedding does the patient use)
Pillow:
None
Synthetic
Feather
Mattress:
Synthetic
Unknown
Feather
Unknown
Are there hypoallergenic coverings on the bedding?
Yes
No
Does this patient use a down comforter?
Yes
No
Floor Covering
Bedroom:
Area Rugs
Ceramic Tile
Wall to Wall
Wood
House:
Area Rugs
Ceramic Tile
Wall to Wall
Wood
HVAC
Humidifier:
Yes
Heating:
Forced Air
Air Conditioning:
No
Radiant
Stove
Central
Wall
None
Unknown
Basement
None
Unfinished
Finished
Is there chronic leakage?
Yes
No
Smoke Exposure
Secondhand Smoke:
Yes
No
Patient Smoke:
Yes
No
Frequency:
Current every day smoker
Current some days smoker
Former smoker
Never smoked
Smoker, current status unknown
Employment:
Inside
Outside
Student
Unemployed
Exposure to (Check all that apply):
Chemicals
Dusty materials
Building materials
Allergens
Young children
No irritants / allergens
Symptoms are:
better
worse
Irritants:
same while at work.
Social History
Race:
White/Caucasian
More than one race
American Indian
Other:
Ethnicity:
Hispanic
Caucasian
Primary
Language
Spoken:
English
Spanish
Other:
African American
Asian
Asian/Pacific Islander
Refuse to Report
Other:
Use of Alcohol:
None
Social
Moderate
Heavy
Caffeine:
Denies
Occasional
Large
Avoids
Coffee
Tea
Review of systems
Constitution
Abuse
Caffeinated soft
drinks
Please put CHECK MARK if patient has had any of these symptoms.
Eyes/Head
ENT
Respiratory
Decreased Appetite
Itchy Eyes
Nasal Congestion/Discharge
Chest Tightness
Chills
Migraine Headaches
Nose Bleeds
Cough
Failure to thrive
Redness of Eyes
Ear Pain
Difficulty Exercising
Fatigue
Sinus Headaches
Post Nasal Drip
Shortness of Breath
Fever
Tension Headaches
Sneezing
Sputum Production
Night Sweats
Swollen Eyes
Snoring
Wheezing
Sleep Problems
Watery Eyes
Sore Throat
Weight Change
Cardiovascular
Tinnitus (ringing in ears)
Gastrointestinal
Hematology
Endocrine
Edema (Swelling)
Abdominal Pain
Anemia
Cold Intolerance
Murmurs
Constipation
Bleeding
Heat Intolerance
Palpitations
Diarrhea
Bruise Easily
Fainting
Reflux (Heartburn)
Swollen Glands
Nausea
Vomiting
Musculoskeletal
Skin
Psychiatry
Allergy
Joint Pain
Acne
Anxiety
Drug
Back Pain
Alopecia
Depression
Food
Muscle Pain
Contact Dermatitis
Developmental Delays
Seasonal
Osteoporosis
Eczema
Hyperactive
Bee Stings
Stiffness
Hemangioma
Irritable
Urticaria/hives
Hives/Swelling
Mood Swings
Rash/Itching
Stress
Warts
Please complete this section for children under the age of 18
Birth Weight
lbs._
ozs.
Complications:
Vaginal Delivery
Feeding:
Formula Only
Breast Fed How Long
Are immunizations up-to-date?
Yes
No
C-Section
Premature:?
Weeks
Transition from breast milk with no
problems?
Problems transitioning from breast milk?