Download Allergy questionnaire - tri

Date:
HISTORY
ALLEBGY
Patienl'sName
Sex:
Firsl
Last
Age:
lnilial
State
Home TeleohoneNo
zip
Parent'sName
Area Code
Number
First
Initial
TO be filled OUt by patient Youranswersto thetollowingquestionswillhelpto determinethecauseol yourallergysymptoms.tt is important
to check
(/) eachquestionas accurately
as possible..
YES
Havetroublewith vour skin?
Eczema
Hives
Have trouble with vour ears?
Popping
Itching
Hearino loss
Fluid in ears
lnfection/Pain
NO
oonl
Know
YES
Whichof thefollowing
do youthinkcauseyour
symptoms
or makethemworse?
NO
Don't
l(n0w
Duringwhatmonthsdo you
usuallvhavesvmotoms?
All months
January
February
March
April
Mav
June
July
August
Havetroublewithvourthroat?
Seotember
Frequentlysore/drainage
October
ItchinothroaVmorth
Have trouble with vour eves?
Redness
Itching
Tearinq
November
December
Describewhatsymptomsbotheryoumost
Puffiness
Havetroublewithvournose?
Clear/colorlessdischaroe
Thick/coloreddischaroe
Nasalitchinq/rubbinq
Whendid your conditionbegin?
Doyouusemedication
reguladyfor nasal
svmotoms?
Constanlstuffiness
Periodicstutfiness
Snitfles
What medication?
Sneezing
Mouth breathinoor snorino
Doesil helo?
Have troubleswith vour chest?
Wheezinowith colds
Wheezingwhenexposedto dust,
pollen,animal,etc.
Wheeze/cough/after exercise
Couoh?
whai kind?
Deep/orproductive
Do any of your blood
relativeshave alleroies?
Haveyou ever had skin
tests for allerqies?
Do vou have alleroies?
Whal are you allergicto?
LOOSe
Constanl
Dryltight
Daytime
Nighttime
ls thereanythingelse
aboutyourproblem
whichyouthinkmight
be important
or unusual?
Areyoursymptomsmild?
Moderate
Severe
Presentmostof thetime
Presentoartof thetime
Present rarelv
Interferinowith vour life
Preventing
manynormal
activities
P/N 904972
More questions on reverseside...
\
YES
o o nl
Xnow
NO
YES
Do you live in: House?
Apartment?
In the city?
Smokersin vour home?
Dovousmoke?
Cigaretles#-lday
Pipe #-/day
Cigars#-/day
Yearssmoked?Sloppedsmokingin 19-
ln the suburbs?
ls vour dwellinq:New?
3-10 vearsold?
11-25 vearsold?
> 25 vearsold?
Have you had any of the
followino?
High blood pressure
Miqraineheadaches
Skindisease
NO
UONI
Know
YES
Do you sleepwith a pillow?
ls it dacron?
ls it loam rubber?
ls it feathefl
Other(describe):
oonl
xn0w
NO
|
|
I
L
I
L
t
I
I
Feather
Foam rubber
Horsehair
Olher (describe):
Heartdisease
Do you take medications
dailvor freouentlv?
Aspirin
Cortisone
Laxatives
Sedatives
Birth control pills
Freouentheadaches
Sinusdisease
Stomachdisease
Asthma
Nasal polyps
Emphysema
Broken nose
Overactivethvroid
Vitamins
Ointments
Nosedrops/sprays
Bronchitis
Nasalsuroerv
Hormones
Underactivethvroid
Hav fever
Deviatedseotum
Hormonaldifficultv
Hives
Food allerov
Drug allergy (describe):
Others(list):
Do youspenda gooddeal
of timein activilies?
Photography
Carpentry
Campino
Sewinq
Gardeninq
Paintino
Cookino
Movies
Hobbies(list):
Do vou use a humidifier?
Do vou have an air
con-ditioner?
At work
At home
ln bedroom
Central
Otherconditions(describe):
Areyoutakingmedication
for anyof theprevious
(describe):
conditions?
:oo
Sports(list):
Other(list):
I
I
l
Doyouthinkyouroccupation
hasanythingto do with
voursvmploms?
Describeyouroccupation:
ls vour heatinosvstemoil?
Gas
Coal
Electric
Other(describe)
Have you eVerhad animals in
Are any materialsused
in your occupationthat
you think have something
to do with your condition?
(describe):
ls heatdeliveredby blower?
Radiators
'Electric
Danels
Other(describe)
At work,areyour
better?
symPtoms
Worse
The same
$-
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