What Is the Reason for Today's Visit?______

Narberth Allergy and Asthma-Havertown Corinna Bowser, MD| Linda D. Green, MD 109 Forrest Ave, Narberth, PA | 850 West Chester Pike, Havertown, PA Phone: 484-270-8584 Fax: 484-270-8799 | Phone: 610-446-4844 Fax: 610-446-3901 E-Mail: [email protected] Web: www.narberthallergy.com [email protected] www.sniffles.com

Patient Questionnaire: What is the reason for today's visit?______

1) Current medications: ______

2) Past Medical History: do you have any chronic conditions? ______3) Do you have any allergies to medications or food? ______What reaction?______What reaction?______What reaction?______What reaction?______

4) Have you had any surgeries (most recent or any surgeries relevant to condition)? Year______What______Year______What______Year______What______2 3 5) Have you been hospitalized over night (outside of surgeries in recent years)? Year______Reason______Year______Reason______Year______Reason______Year______Reason______

6) Anybody else in your family with allergies, asthma, eczema, food allergies? ______

7) Smoker? □No □Yes ______cigs/day for ______years

8) Living conditions:

Pets: □ No □Yes ______

□ Wall to wall carpet ______□Wood floors______□other ______

Heat □Central air heat □ Radiator □ baseboard heat

Cooling □Central air cooling □Window units

Smokers in home □Yes □No

Mold or mildew in home (where you can see it or smell it) □Yes □No 9) Have you had

□ Flu vaccine When? ______

□ Pneumonia vaccine When?______