Patient’s Name_______________________________________________Birthdate____/____/____
ENVIRONMENTAL HISTORY:
Geographic history:
Where were you born?________________________________________________________________________
In what state (country) did you spend most of your life?_____________________________________________
How long have you lived in Oregon?_____________________________________________________________
Home environment:
Type of heating:______________________________________________________________________________
How old is your mattress?__________________pillow?_______________check if waterbed________________
Yes No Is your pillow covered with zip-on hypoallergenic covers? Yes No Synthetic
Yes No Do you have a feather comforter?
Yes No Is there carpeting in your bedroom? How old is it?_____________
Yes No Does your house have dampness, mold, or mildew problems?
How old is your home?____________ How long have you lived there?____________
Is it an apartment?____________ Is it a manufactured home?____________
How many pets come inside your home (specify number)?
__________dogs __________cats __________other (specify) _______________________________
Yes No Do you have horses or other outside animals?
Specify:____________________________________________________________________________________
Lifestyle history:
Yes No Have you ever smoked or vaped? Date quit____________________________________________
Yes No Do you presently smoke or vaped?
How many
years have you or did you smoke or vape? _________________________________________
How many packs (average) per day?_____________________________________________________________
Yes
No Does anyone else in the home smok
e or vape? Who?
_________________________________________
Yes No Do you use alcohol? How much/how often?_________________________________________
Yes No Do you use recreational drugs? What?______________________________________________
Yes No Do you have an Advance Directive?
Occupational history:
What type of work do you do?_________________________________________________________________
__________________________________________________________________________________________________________________________________________
Do you use over-the-counter nose sprays? Yes No Occasionally Regularly
Have you ever received a corticosteroid (cortisone) injection for allergies?
Yes No
Have you had sinus surgery?
Yes No Date______________________________________________
Date of last chest x-ray:________________________ Date of last sinus CAT scan:___________________
____
Review of Systems: Have you ever had any of the fol
lowing? Circle or check all that apply:
Frequent headaches High blood pressure Stomach or digestive problems
Ear infections/Sinus infections Thyroid problems Kidney trouble
Glaucoma/Cataracts Skin problems Liver trouble
Heart trouble
Tuberculosis Neurological problems
Psychiatric
Diabetes
Family Health:
Yes No Is there a history of allergy in your family? If yes, please indicate:
Allergies Hay feve
Asthma Sinus problems Eczema Hives
Parents
Siblings
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