Patient Encounter Form Page 3

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OTHER INFORMATION
Patient’s Name
Past Medical History:
Hospitalizations:
ER Visits:
Surgery:
Medication(s) Now Used:
Smoking Habits?
Cigarettes
Cigars
Pipe
Other
Number per day?
How Long?
Months
Years
Drink Alcoholic Beverages?
YES
NO
Social
Habitual
Alcoholic History
Drug Use?
Often/Presently
Sometimes
Never
Past
INSTRUCTIONS:
CIRCLE OR UNDERLINE ITEMS WHICH AFFECT YOUR PROBLEM
IRRITANTS:
Cleansers, Detergents, Cooking Odor, Perfume, Powder, Tobacco Smoke, Other Smoke: ________________,
Moth Balls, Motor Fumes, Pain Lacquer, Wax, Glue, Insect Spray, Fertilizers, Ammonia, Room Deodorants,
Chemical Fumes, Clorox, Other:
TOILETRIES:
Soap, Shampoo, Shaving Cream, After Shave, Spray Deodorant, Hair Spray, Hair Tonic, Hair Tonic, Hair Dye,
Hand Cream, Make-Up, Toothpaste, Denture Cream, Mouthwash, Nail Polish, Other:
Foods:
Milk, Cheese, Eggs, Fish, Shellfish, Nuts, Chocolate, Alcohol, Wine, Beer, Juices, Seasonings, Vegetable,
Strawberries, Products Of Wheat, Cold Liquids, Other:_____________________________________
Drugs:
Penicillin, Sulfer, Over-the-counter Drugs (Specify:_________________________________________________)
Other: ___________________________________________________________________________________
PETS:
Which of these do you have as pets: Cat, Dog, Bird, Horse, Hamster, Rabbit, Other:
Is your condition worse around pets?
Specify:
INSECT BITE or
Large Swelling, Weakness, Sweating, Shortness of Breath, Stuffy Nose, Wheezing, Other:
STINGS:
WEATHER:
Hot, Cold, Humid, Damp, Pollution, Smog, Sunlight, Air Conditioning, Change in Temperature, Other:
NEW
Wool, Silk, Sweater, Coat, Shoes, Dry-Cleaned Clothes, Starched Clothes, Other:
(Unwashed)
CLOTHING:
CONTACTANTS:
Poison Ivy, Cut Grass, Cut Flowers, Household Plants, Hay, Christmas Trees, Plastic, Rubber, Fiberglass,
Dust, Wool, Blankets, Feather Pillows, Mattress, Overstuffed Furniture, Rugs, Furs, Stuffed Pads, Jewelry,
Shoe Polish, Other:
Patient Encounter Form-AW
page 3 of 11
9/17/2013

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