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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Anything special we need to know
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Do you use online scheduling?
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Want access to online portal?
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Medical History
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Past Medical History
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Past Medical History Freewrite
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Past Surgical History
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Comments
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Childhood illnesses
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Comments
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Childhood Immunizations
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Comments
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Date of last PE
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PCP
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PCP Contact Information
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Family History
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Father's MH
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Comments
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Mother's MH
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Comments
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Sibling(s)' MH
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Comments
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Grandparent's MH
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Comments
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Children(s)' MH
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Comments
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Social History
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Marital Status
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Living Arrangements
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Potential Environmental Pathogen
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Sexual Hx
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Comments
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Occupation
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Caffeine
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Alcohol
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Other substances
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Comments
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Patient's diet
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Comments
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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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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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History provided by
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When did you first observe symptoms?
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Had a previous diagnosis of allergy?
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If has, have/have not the medications helped
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had/had not tried immunotherapy
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immunotherapy did/did not help
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is/is no family history of allergic disorders
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if is, select the family members
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has a history of _____
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Primary symptoms
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Do you have Skin Symptoms?
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Please turn on if you have Skin symptoms
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Skin symptoms are noted to____
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Do you have Eyes Symptoms?
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Please turn on if you have Eyes symptoms
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Eye symptoms include____
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Do you have Ears Symptoms?
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Please turn on if you have Ears symptoms
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Ear symptoms are reported at times to include___
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Do you have Nose Symptoms?
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Please turn on if you have Nose symptoms
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Nasal symptoms include____
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Do you have Throat and Mouth?
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Turn on if you have Throat and Mouth symptoms
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Throat and Mouth symptoms
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Do you have Chest Symptoms?
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Please turn on if you have Chest symptoms
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Chest symptoms include____
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Do you have Gastrointestinal Track symptom?
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Turn on if u have Gastrointestinal Track symptom
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Chronic symptoms
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Do you have musculoskeletal system?
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Turn on if u have Musculoskeletal system symptom
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Bone and joint symptoms
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How your symptoms have been?
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When are your symptoms most severe?
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Symptoms are exacerbated by?
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When are your symptoms better?
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Animal exposure includes
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If other, please specify
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Exposure to animals that cause symptoms
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If other, please specify
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Other allergic reaction appear to occur with
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Smoking habits
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Do you have history of food related symptoms?
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If yes, symptoms flare
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