FIM – Pediatric New Patient Part 4 Pediatric New Patient FMI Part 4 Name* First Last Date DOB Email* ENVIRONMENTAL HISTORY Please check appropriate box Exposures Mold in bathroomPastCurrentMold in cellar, crawl space, or basementPastCurrentDamp cellarPastCurrentMoldy, musty school/daycarePastCurrentPest extermination – inside/outsidePastCurrentTobacco smokePastCurrentWell waterPastCurrentChemicalsPastCurrentElectromagnetic radiationPastCurrentCarpet in bedroomPastCurrentHad water in basementPastCurrentCarpet in most parts of the housePastCurrentMold visible on exterior of housePastCurrentFeather or down beddingPastCurrentHeavily wooded or damp surroundingsPastCurrent ABOUT YOUR PARENTS When were your parents married? If separated, when? If divorced, when? If remarried, when? Custody Arrantements Mother Personal Age at your BirthEducationHigh SchoolTradeSome CollegeCollege GraduateAdvanced DegreesEthnicityBlood TypeABA/BODon't Know Father Personal Age at your BirthEducationHigh SchoolTradeSome CollegeCollege GraduateAdvanced DegreesEthnicityBlood TypeABA/BODon't KnowUpon Submission you will be taken to Part 5. You can visit Patient Forms for each section.