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Allergy History Form   Please Download Allergy History Form * Name Please enter Name Today’s Date *Date of Birth Please enter Date of Birth Account # *Referred By Please enter Referred By Name   PLEASE FILL THIS SIDE OF THE FORM. 1. Why did you come today?   2 Describe Your Symptoms.   Nose: Runny Stuffy Itchy Drainage Face: Swelling Pain Pressure     Throat: Sore Swelling         Ears: Infections Pain         Chest: Shortness of Breath Wheezing Cough     3. Are Your Symptoms Worse During a Particular Time of Year?     If Yes, Which Season Spring Summer Fall Winter 4. Are Your Symptoms Aggravated By Exposure to:   Grass Trees Fall Weeds Dust Dogs Other Animals Drugs Insects Foods           If Yes, Which Ones   1 3 2 4   Other Foods:   5. Past Medical History   Who in Your Family Has Allergy? Any Current Medical Problems? Any Past Medical Problems 6. WHAT MEDICATIONS ARE YOU CURRENTLY TAKINGS?   1 3 2 4 7. Environmental History Where are you living?   Where are you living?   House Apt Age of Home   Type of Heating System?   Central Force Air Space Heater Other   Do You Have Air Conditioning?   Yes No   What Type of Flooring Have You?   Carpeting Long Pile Hardwood Carpeting Short Pile Linoleum   What Type of Bedding?   Covered Pillow Lots of Books Covered Mattress Curtains Stuffed Animals Blinds   Any Other Information You Wish to Report?   Security Code   Type this security Code In text box:*   Verification code are not case-sensitive Please enter Verification Code

Allergy History Form New Patient Information Patient Consent New Patient Information New Patient Record Patient Consent Ethnic Health America Network The Ethnic Health America Network, is a multimedia network of radio, television, print and... KPFA Our program airs on KPFA (94.1 FM) on Mondays from 2:00 pm – 3:00 pm (Pacific Standard Time) and is designed to give our listeners an...

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