Adult New Patient Form Part 4 Adult 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 surroundingsPastCurrentDo you have known adverse food reactions?Do you have any food allergies or sensitivities?Do you have any adverse reactions to caffeine?Do you adversely react to: (check all that apply) MSG Aspartame (Nutrasweet) Bananas Garlic Onion Cheese Citrus foods Chocolate Alcohol Red wine Sulfite containing foods (wine, dried fruit, salad bars) Preservatives (ex. Sodium benzoate) Which of these significantly affect you? Check all that apply. Cigarette smoke Perfumes/Colognes Auto Exhaust Fumes Have you ever been told you have Gilbert’s syndrome or a liver disorder?YesNoDo you have known history of significant exposure to any harmful chemicals such as the following? Herbicides Insecticides Pesticides Organic Solvents Heavy Metals Chemical Name, Date, Length of ExposureDo you dry clean your clothes frequently?YesNoDo you or have you lived or worked in a damp or moldy environment or had other mold exposures?YesNoDo you have any pets or farm animals?YesNoUpon Submission you will be taken to Part 5. You can visit Patient Forms for each section.