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Reason you are here today for evaluation
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Name of previous allergist?
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Skin test done?
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If positive, what are you allergic to?
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Did you receive allergy shots?
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List all current medications you are taking
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Allergic to any medications?If so, please list
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Medication/reaction
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Medication/reaction
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Allergic to any foods?If so, please list below
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Food/reaction
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Food/reaction
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List any health problems you have had
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If asthma, how long, is it getting worse?
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Describe triggers of asthma
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Day time symptoms
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Night time symptoms
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Hospitalized or gone to the emergency room
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Past surgeries you had with the approximate date
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Family History - Mother
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If other,list high blood pressure/diabetes, etc
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Father
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If other,list high blood pressure/diabetes, etc
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Brothers
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If other,list high blood pressure/diabetes, etc
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Sisters
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If other,list high blood pressure/diabetes, etc
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Social History - Do you smoke?
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If yes, Number of cigarettes per day
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If No, when did you quit
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Do you live with someone that smokes?
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Are you currently employed/in school
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If yes, Occupation/School
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Environmental History - Type of residence
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Are your symptoms worse_____
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Number of years living in this area?
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Type of flooring in bedroom
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If other, please specify
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Any indoor pets?
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If yes, please list type of pets and how many
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History of flooding in your residence?
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Visible mold or mildew in your home?
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Use of HEPA filter in your home?
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Dust mite proof encasings on mattress/pillows?
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General
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Skin
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Headaches
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Eyes
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Nose
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Ears
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Throat
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T/A (Age)
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Chest
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Cardiovascular
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G.I.
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Stools
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G.U.
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Endocrine
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Musculoskeletal
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Females
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Neurological
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Psychiatric
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Reviewed by the doctor (Only for doctor use)
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