|
HPI
|
c/o
• • •
|
|
if urticaria, please select
|
duration
|
|
Denies an specific food/drug/contact/infectious
|
Antihistamines
• • •
|
|
please select
|
If there is airway involvement, comments
|
|
If asthma, comments
|
symptoms
• • •
|
|
If sinusitis, comments
|
please select
• • •
|
|
If bronchitis, comments
|
please select
• • •
|
|
comments
|
|
|
Severity
|
Frequency
|
|
Duration
|
Seasonal (Months)
|
|
Time of day
|
|
|
AGGRAVATING/PRECIPITATING FACTORS
|
|
|
Location
|
Weather
• • •
|
|
Please select
• • •
|
Please select
• • •
|
|
Mold/Mildew
• • •
|
House dust
|
|
Chemical Irritants
• • •
|
Please select
• • •
|
