<p> 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</p><p>Patient Questionnaire: What is the reason for today's visit?______</p><p>1) Current medications: ______</p><p>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?______</p><p>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______</p><p>6) Anybody else in your family with allergies, asthma, eczema, food allergies? ______</p><p>7) Smoker? □No □Yes ______cigs/day for ______years </p><p>8) Living conditions:</p><p>Pets: □ No □Yes ______</p><p>□ Wall to wall carpet ______□Wood floors______□other ______</p><p>Heat □Central air heat □ Radiator □ baseboard heat </p><p>Cooling □Central air cooling □Window units </p><p>Smokers in home □Yes □No</p><p>Mold or mildew in home (where you can see it or smell it) □Yes □No 9) Have you had </p><p>□ Flu vaccine When? ______</p><p>□ Pneumonia vaccine When?______</p>