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Are you a new patient?
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ALLERGY QUESTIONNAIRE
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Referring Physician?
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Occupation?
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Most concerning symptoms?
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Symptoms began?
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Symptoms year round or seasonal?
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What Month do symptoms occur?
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Best Month?
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Worst Month?
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Frequency of Attacks?
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Symptoms worse during?
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Duration of symptoms?
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Longest period symptom free?
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Symptoms better, worse, same?
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Allergic to any medications?
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If yes, which medication?
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Reaction
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If yes, which medication?
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Reaction
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if yes, which medication?
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Reaction
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Any food allergies?
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More than 3-4 "colds" per year
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Prone to frequent infection?
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If yes, type and frequency
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Is nervousness a problem?
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If yes, Describe
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Allergic reaction to bee stings?
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Describe
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Past medical history:
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Other medical problems?
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Missed work or school?
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Reason?
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Duration
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Hospitalized for allergy/asthma?
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If yes, Date
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Hospital
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Physician
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Describe the symptoms
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SYMPTOMS
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Chest symptoms?
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Nose symptoms?
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Ear symptoms?
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Eye symptoms?
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Throat symptoms?
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Skin Symptoms?
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Pollen Allergy?
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Animal hair/dander allergy?
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Dust allergy?
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Odors causing symptoms?
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Other possible causes?
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Foods causing symptoms?
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HOME ENVIRONMENT
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Patient share a bedroom?
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How many beds?
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Type of Mattress?
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Other Mattresses in house?
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Patient type of bed springs?
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Other's type of bed springs?
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Patient's pillow is made of?
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Other pillows in house?
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Blankets?
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Carpet?
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Carpet Pad?
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Stuffed toys in bedroom?
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Type of stuffing in toys?
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Carpets in living room?
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Rug pad
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Carpets in other rooms
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Rug Pad
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Overstuffed furniture age
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Overstuffed furniture's stuffing
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Other stuffing
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Furniture upholstrey
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Other Upholstery
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Heating system
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Furnace filter present
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How often filters changed/clean
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Airconditioning
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Swamp Cooler
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Electronic air cleaners
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Humidfiers
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Age of home
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Type of construction
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Basement/home ever smelled
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Basement
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Years at present address
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Previous residence city
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Previous residence state
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How long in previous residence
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Change in local affected symptom
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How has it affected
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Trees neighborhood contain
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Lawns neighborhood contains
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Fields neighborhood contains
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Farms neighborhood contains
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Water neighborhood contains
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Animal present indoor
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Animal present outdoor
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Anything a factor for allergy
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WORK EXPOSURE
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Year in school
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Job title
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Years performed
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Heating system at work
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Air conditioning at work
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Humidification at work
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Air filters at work
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Dust at work
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Odor at work
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Fumes(smoke) at work
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PREVIOUS ALLERGY STUDIES
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Skin test done before
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Doctor seen for allergy testing
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Date skin test done
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Results of skin test
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Duration injection/treatment
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Gamma globulin test done
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When was the test done
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Where was test done
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Result of test
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DIET
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Food eliminated
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Duration Food eliminated
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Results of diet
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MEDICATIONS
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Current medication
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Current frequency
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Used the following
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Date first and last used
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Frequency of use
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Medication used for treatment
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FAMILY HISTORY
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Father
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Father's Age
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Father's Health
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Allergy(Father)
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Other disease(father)
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Mother
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Mother's Age
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Mother's Health
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Allergy(Mother)
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Other disease(Mother)
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Brother's
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Brother's Age
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Brother's Health
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Allergy(Brother's)
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Other Disease(Brother)
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Sister's
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Sister's Age
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Sister's Health
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Allergy(Sister's)
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Other Disease (Sister)
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Patient married?
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Number of children
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Allergies in children
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Spouse have allergies?
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Type of allergy
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IMMUNIZATIONS
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Small pox vaccine Date
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Typhoid vaccine Date
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German measles vaccine
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Diphtheria vaccine date
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Polio Vaccine Date
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Whooping cough vaccine
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Influenza vaccine Date
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Mumps Vaccine Date
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Yellow Fever vaccine date
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Tetanus vaccine Date
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Red Measles vaccine date
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Other vaccine Date
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Reaction to Immunization
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Describe reaction
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Last tuberculin test date
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Type
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Result
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OPERATIONS AND HOSPTIALIZATIONS
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Hospital
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Year
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Physician
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Reason
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Hospital
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Year
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Physician
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Reason
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INJURIES
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Type of accident?
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Year?
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Nature of injury?
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Type of accident?
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Year?
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Nature of injury?
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HEALTH HABITS
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Drink Alcohol?
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Daily amount?
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Smoke Tobacco?
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Daily Amount?
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Drink Coffee?
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Daily Amount?
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Drink Tea?
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Daily Amount?
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Exercise?
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Take Vitamins?
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Brand?
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Other's smoke in house?
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OTHER COMMENTS
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Other comments?
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