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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 $- Kabi Pharmacia Dlagnoatlcr