bamapeds.com - Allergy History Form

Allergy History Form

BAMA Pediatrics
Name:*

First NameLast Name
Past Medical History

No Significant Past Medical HistoryAbuse/NeglectAllergic RhinitisAnemiaAngiodemaAsthmaAsthma Mild IntermittentAsthma Mild PersistentAsthma Moderate PersistentAsthma Sever PersistentADHD/ADDBlood DisorderBronchitisCGDCHFCOPDCancerCerebral PalsyChicken PoxConcussionCongenital Heart DiseaseConstipationCroupIntellectual DisabilityPDD/ASDSpecific DisorderASDDiabetesMedication/Drug Use D...EczemaEnuresisEsophageal RefluxEyesite ProblemsGebrile ConvulsionFracturesGERDHeadacheHearing LossHeart DiseaseHyperlipidemiaHypertensionImmunologic DisorderInfluenzaJaundiceKidney DiseaseLiver, Stomach or Bowel DiseaseLung AbscessMeaslesPrevious Mental IllnessMigraineMononucleosisMumpsNeuro IllnessOsteomyelitisOtitis MediaPneumoniaPreterm InfantPulmonary EmbolismThyroid DisorderRecurrent URIScarlet FeverSeizureSinusitis-MultipleSkin ProblemsSkin AbscessSleep ApneaSpecial EducationSpeech DifficultiesStaph InfectionTonsilitisTuberculosisURIUTIUrticariaVesicoureteral Reflux
Other Past Medical History, Please Specify:
ER Visits and Hospitalizations
Previous Emergency Room Visit

YesNo
Average Number of ER visits per year
Frequent Emergency Room Visits

YesNo
Previous Hospitalizations

YesNo
Endotracheal Tube Insertion

YesNo
History Unobtainable - HPI

YesNo
Admission to Hospital MICU

YesNo
Spirometry Peak Expiratory Flow
Allergy History
Allergy Sensitivity Testing

YesNo
Food Allergy

YesNo
Allergen Desensitization

YesNo
Latex Allergy

YesNo
Insect Allergy

YesNo
Drug Allergy

YesNo
Immunizations
Immunization Reviewed And Current

YesNo
Immunization Record Unavailable

YesNo
Past Medical/Surgical History [Use for Free Text]

YesNo
Surgical HX

History of Prior SurgeryMyringotomyTonsillectomy with AdenoidectomyAdenoidectomyCholecystostomyKnee Surgery
Living In-Housing:
Living With:
Living Environment

Secondhand Tobacco smoke in homeHousing Heating SourceHousing Cooling Source CentralHousing Has inadequate CoolingHousing water source not city waterHousing water source wellHousing water source not city waterExposure to moldsWall-to-Wall carpetingCarpet RemovalDrapery RemovalMattress/Pillow CoversElectrostatic Dust FilterHEPA FiltersResidential Type
Recent Contact with pets or other animals

YesNo
Recent Contact with dogs(s)

YesNo
Number of Dogs
Recent Contact with cat(s)

YesNo
Number of Cats
Recent Contact with bird(s)

YesNo
Number of Birds
Recent Contact with hamsters

YesNo
Number of Hamsters
Recent Contact with guinea pigs

YesNo
Number of Guinea Pigs
Recent Contact with rabbits

YesNo
Number of Rabbits
Recent Contact with horses

YesNo
Number of Horses
Recent Contact with dairy cows

YesNo
Recent Contact with cattle

YesNo
Recent Contact with pets or other animals livi...

YesNo
Recent Contact with insects

YesNo
Education-Child
Education Cont.
Education and Work HX
Alcohol and Drug Use

Alcohol ConsumptionSocial DrinkerNever Drank AlcoholStopped Drinking AlcoholDrug Use
Never a Smoker

YesNo
Former Smoker

YesNo
Smoking Cigarettes

YesNo
Number of packs
Former Smoker

YesNo
Stopped Smoking

MonthDayYear
Date
Former Cigar Smoke

YesNo
Former Pipe Smoker

YesNo
Former Smoker Cigarettes

YesNo
Wishing to Stop Smoking

YesNo
Unsuccessful attempt(s) to stop smoking

YesNo
Exposure to secondhand cigarette smoke

YesNo
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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Allergy History Form

ER Visits and Hospitalizations

Allergy History

Immunizations