bamapeds.com - Allergy History Form

Allergy History Form

BAMA Pediatrics
Name:

First NameLast Name
Past Medical History
Other Past Medical History, Please Specify:
ER Visits and Hospitalizations
Previous Emergency Room Visit
Average Number of ER visits per year
Frequent Emergency Room Visits
Previous Hospitalizations
Endotracheal Tube Insertion
History Unobtainable - HPI
Admission to Hospital MICU
Spirometry Peak Expiratory Flow
Allergy History
Allergy Sensitivity Testing
Food Allergy
Allergen Desensitization
Latex Allergy
Insect Allergy
Drug Allergy
Immunizations
Immunization Reviewed And Current
Immunization Record Unavailable
Past Medical/Surgical History [Use for Free Text]
Surgical HX
Living In-Housing:
Living With:
Living Environment
Recent Contact with pets or other animals
Recent Contact with dogs(s)
Number of Dogs
Recent Contact with cat(s)
Number of Cats
Recent Contact with bird(s)
Number of Birds
Recent Contact with hamsters
Number of Hamsters
Recent Contact with guinea pigs
Number of Guinea Pigs
Recent Contact with rabbits
Number of Rabbits
Recent Contact with horses
Number of Horses
Recent Contact with dairy cows
Recent Contact with cattle
Recent Contact with pets or other animals livi...
Recent Contact with insects
Education-Child
Education Cont.
Education and Work HX
Alcohol and Drug Use
Never a Smoker
Former Smoker
Smoking Cigarettes
Number of packs
Former Smoker
Stopped Smoking

MonthDayYear
Date
Former Cigar Smoke
Former Pipe Smoker
Former Smoker Cigarettes
Wishing to Stop Smoking
Unsuccessful attempt(s) to stop smoking
Exposure to secondhand cigarette smoke
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.
Signature of Patient or Representative:
Date:

MonthDayYear
Date
If not Self, Relationship to Patient
Should be Empty:

Allergy History Form

ER Visits and Hospitalizations

Allergy History

Immunizations