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Reasons for Visit
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Clinical Study
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Skin
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Allergies for 2 years
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New Field
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Eye Problems
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Asthma
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Red Eyes
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Sinus
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Cough
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Drug Allergy
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Autoimmune Problems
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Earache
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Diarrhea
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Food Allergy
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Seasonal Allergies
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Headache
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Angioedema
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Abnormal Blood Tests
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Difficulty Breathing
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Lymph nodes
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Difficulty Swallowing
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Chronic itching
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Increased Infections
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Eye Drainage
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Facial Pain
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Fever
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Immune deficiency
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AI Review of Systems
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Top 5 Symptoms
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General
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Age when symptoms first observed
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Eyes
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Skin
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Nose
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Ears
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Cardiovascular
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Mouth/Throat
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Stools
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Chest
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Endocrine
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G.I.
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Females
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Musculoskeletal
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Psychiatric
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G.U.
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Allergy to Penicllin
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Neurological
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Food Reactions (5-60 minutes after meals)
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Blood/Lymph
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Specific Foods causing reactions 1-2 hours
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Previous Diagnosis of Allergy and Treatments
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Foods causing symptoms in 2 -24 hours
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AGGRAVATING/PRECIPITATING FACTORS
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Insect Sting Allergy
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Symptoms Locations
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Latex Allergy
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Seasons when symptoms are severe
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Skin Reaction(s)
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Symptoms are Better
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Chemicals that Cause Symptoms
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Frequency & Severity of Symptoms
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Other Known Allergic Reactions
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Symptoms Worsen by
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Past Treatments
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Animals, Insects Causing Symptoms
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Prior Allergy History
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Other Animals Insects Causing Symptoms
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Medications used
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Weather
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Frequent Infections
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Social Habits
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# Ear Infections in the Past Year
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Alcohol Drinking Habits
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# Sinus Infections in the Past Year
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Smoking habits
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# Skin Infections during Lifetime
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Environment
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# Pneumonia during Lifetime
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Current Living Environment
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Any Risk factors for Infection
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Exposure to Animals
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Exposure to Other Animals
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Residence
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Bedroom Pets
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Bedroom
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