LABEL OR PRINT

NAME
CH MRN
DOB

ALLERGY NEW PATIENT HISTORY

Allergy Program
Page 1 of 3

Date of Birth
Patients First Name

Patients Last Name

Other doctors involved with your childs care:

PCP Address:
BOSTON CHILDRENS HOSPITAL, 300 LONGWOOD AVE., BOSTON, MA 02115

Patient Phone #

Who referred you to the Allergy Program?

My childs primary care provider
A friend/relative
Self-referred
Another physician:

Primary Care Physician/Pediatrician:

Do you want a letter sent to:

GENDER M F

My childs primary care provider

Referring MD

Another physician:

Please tell us about the problem or question that brought your child to the Childrens Hospital Allergy Program:
Describe any special testing or procedures related to this problem (e.g. allergy testing, blood tests, X-rays/scans, endoscopies)?

What medicines is your child currently taking?

Medicine

Last time
given?

Dose

Taken how often?

How well does it work?

Very Well

Just OK

Not at all

Is your child taking any alternative or homeopathic medicines? If yes, please list.

What other medicines have you previously tried for your childs problem?
Medicine

How long ago was the

medicine stopped?

Length of time
on the medicine

Reason for stopping the medicine

Is your child allergic to any foods? Are any foods currently being restricted from your childs diet? Please describe:

151845

Rev 12/12

Is your child allergic to medications or latex? Please describe:

Continued on other side

LABEL OR PRINT
NAME

ALLERGY NEW PATIENT HISTORY

Allergy Program
Page 2 of 3

CH MRN

Has your child been diagnosed or suspected to have any of the following:
Asthma?
Yes
No
If yes: Has your child been hospitalized?
Has symptoms with exercise/activity?

Yes
Yes

No
No

Yes
In the ICU?
Taken oral steroids?

No
Yes

Yes
No
Intubated?
No If yes, how often?

Yes
No
Eczema?
How often does your child bathe?
If yes: What skin moisturizers are used?
Yes
No
Yes
No
Has your child had skin infections?
Difficulty sleeping due to itching?
Yes
No
Has your child had eczema herpeticum?
Yes
No (If yes, please notify clinic upon arrival)
Has your child had a drug resistant staph aureus infection (MRSA)?
Yes
Nasal/Eye Allergies?
If yes: What symptoms?
Other symptoms
What seasons are worse?

No
Sneezing

Congestion
Post-nasal drip
Runny nose
What triggers your childs symptoms?
Summer
Fall
Winter
Always bad

Spring

Yes
No
Increased frequency/severity of infections?
If yes: What type of infections?
Ear infections
Sinus infections
Pneumonias
How many course of antibiotics has your child taken in the past 12 months?
Was your child born

Full-term

Premature

Via normal delivery

Via C-section

Red itchy eyes

Bronchitis

Other

Requiring supplemental oxygen

Has your child had any other medical problems or diagnoses?

Has your child been hospitalized or had any surgeries (If yes, please describe)?
Yes
No
Are your childs immunizations up to date?
Did your child receive the influenza vaccine this year?
Yes

SOCIAL HISTORY:

Fathers/Guardians Occupation:
Mothers/Guardians Occupation:

No

Siblings and their ages

Mother
Father
Both
Other
Who are the legal guardians?
Yes
No
Does your child attend school/daycare?
Number of days of missed school this year?
If yes: What grade?
Your child participates in what types of sports/activities?

FAMILY HISTORY: Please indicate if the patients parents, grandparents, or siblings have had any of the following conditions:
Condition
Cystic Fibrosis
Thyroid Disease

Condition
Celiac Disease
Other Autoimmune Disease

Relation to patient

No family history of any of the above

Asthma

Mother
Father
Brothers and sisters
Mothers brothers and sisters
Fathers brothers and sisters
Mothers parents
Fathers parents

Nasal/Eye
Allergy

Eczema

Relation to patient

Food Allergy

Drug Allergy

Frequent
Infections

Continued on next page

ALLERGY NEW PATIENT HISTORY

Allergy Program
Page 3 of 3
ENVIRONMENTAL HISTORY:
Does your child live in:

Multiple home settings

An apartment

Do you have a basement?

Climate Control:

Hot water heat

Central A/C
Humidifier

Does your home have?

Flooring:

Yes

Hardwood

Exposure to Pets:

No

No

Mold or mildew

LABEL OR PRINT
NAME
CH MRN

A house
If Yes: Is it

Finished

Steam heat
Window A/C
Dehumidifier

Tile/linoleum

Wall to wall carpeting

Yes (If yes, please describe):

Does your childs bedroom have?

Stuffed animals

No

Area rugs

Rugs

Humidifier

Air cleaner/purifier

Damp

Water stains

Yes (who)?

Air conditioning

Other

Dry

Forced hot air

Air filters
Other

Damp or musty smell

Do you or any of your childs caretakers smoke?

BOSTON CHILDRENS HOSPITAL, 300 LONGWOOD AVE., BOSTON, MA 02115

A multifamily house/condo

Has flooded

Wood stove
Air cleaner/purifier

Mice

Cockroaches

Other

Carpeting

None

Blinds

Feather pillow

Allergy-proof mattress or pillow covers

School, work or day care environment (please describe)

Space heater

Down comforter

Curtains

REVIEW OF SYSTEMS
Has your child been experiencing or diagnosed with any of the following?
Mark N/A if unable to assess
Constitutional

Yes No N/A

Yes No N/A

Respiratory

Hot or cold intolerance

Wheezing
Cardiac

Poor weight gain

Thyroid disorders

Yes No N/A

Changes in appetite

Diabetes

Delayed puberty

Heart murmur
Yes No N/A

Skin

Heart palpitations/irregular heartbeat

Yes No N/A

Heart defects

Red or itchy eyes

Blurred or altered vision

Gastrointestinal

Sensitivity to light

Rash
Yes No N/A

Diarrhea
Yes No N/A

Birth marks or large moles

Musculoskeletal
Joint pain/swelling

Abdominal pain
Neurologic

Nausea/Vomiting

Post nasal drip/nasal discharge

Acid reflux/heartburn

Ear or throat pain

Dizziness or lightheadedness

Enlarged liver or spleen

Loss of smell

Weakness/numbness/tingling
Seizures

Yes No N/A

Hematologic
Yes No N/A

Easy bruising or bleeding

Yes No N/A
Headaches

Blood in stool

Nose bleeds
Nasal polyps

Yes No N/A
Muscle pain

Constipation

Nasal congestion/snoring

Urinary

Excessive thirst

Shortness of breath

Fevers
Chills or night sweats

Ear/Nose/Throat

Yes No N/A

Cough

Feeling tired

Ophthalmologic

Endocrine

Psychiatric

Yes No N/A

Swollen glands

Hyperactivity disorder

Increased frequency of urination

Anemia

Depression or anxiety

Urine infections

Low white blood cell/platelet counts

Sleep disturbances

Pain with urination

Further Details or other symptoms:

Person completeing this form

Relationship to patient

Date

Clinician Signature / Title

Print

TIME

Date