Form: Medical history: for new ... - Allergy, Nutrition
Vickerstaff Health Services Inc.
ALLERGY AND SENSITIVITY EVALUATION FORM
Name________________________________________ Gender______Age_______ Date______________________
1. Please indicate your problems by checking the appropriate boxes:
|1. ( Rhinitis (runny nose, nasal |17. ( Eczema |33. ( Irritable bowel syndrome (IBS) |
|congestion), perennial (year | | |
|round) |18. ( Contact dermatitis (from |34. ( Inflammatory bowel |
| |skin contact with a |disease (IBD) |
|2. ( Rhinitis, seasonal, allergic |substance) | |
|(only during certain times of | |35. ( Spastic colon |
|the year (hay fever)) |19. ( Angioedema (swelling of | |
| |lips, face, or tongue) |36. ( Chronic diarrhea |
|3. ( Nasal polyps | | |
| |20. ( Urticaria (hives) |37. ( Constipation (less than 1 |
|4. ( Allergic conjunctivitis | |bowel movement per day) |
|(itchy, watery eyes) |21. ( Anaphylaxis (itching, | |
| |swelling, breathing |38. (Abdominal bloating after |
|5. ( Asthma |difficulty, collapse) |meals |
| | | |
|6. ( Repeated chest infections |22. ( Immediate food allergy |39. (Abdominal pain |
| |(exposure causes itching, | |
|7. ( Chronic sinusitis, face |swelling, hives) |40. ( Frequent gas/flatulence |
|ache, sinus pain | | |
| |23. ( Food or food additive |41. ( Nausea |
|8. ( Serous otitis media |intolerance (not #22) | |
|(accumulation of fluid in the | |42. ( Heartburn |
|ear) |24. ( Chronic anal itch (not | |
| |caused by hemorrhoids) |43. ( Acid reflux |
|9. ( Repeated earaches | | |
| |25. ( Mental depression (brain |44. ( Vertigo |
|10. ( Migraine with visual |"fog"; confusion) | |
|disturbances | |45. ( Fibromyalgia (Chronic fatigue |
| |26. ( Hyperactivity; Attention |syndrome (CFIDS) |
|11. ( Headaches, migraine |deficit disorder (ADD) |(diagnosed by doctor) |
| | | |
|12. ( Other headaches |28. ( Ulcerative colitis |46. ( Chronic fatigue (not #45) |
| | | |
|13. ( Chemical or fume |29. ( Crohn's disease |47. ( "Candida syndrome" |
|intolerance (severe, when | | |
|exposed by breathing) |30. ( Celiac disease (Gluten |48. ( Other (specify): |
| |sensitive enteropathy) | |
|14. ( Rheumatoid arthritis | | |
| |31. ( Urinary tract symptoms | |
|15. ( Joint pains |(not due to infection) | |
| | | |
|16. ( Muscle pains |32. ( Chronic vaginal symptoms | |
| |("yeast" infection) | |
2. I know I have, or have been previously diagnosed with:
( Inhalant allergy (I react adversely when I breathe in pollen, mold spores, dust, animal dander)
( Food allergy or food additive intolerance (I react adversely when I eat something)
( Chemical or fume sensitivity (I react adversely when I breathe chemical odors or fumes)
( Anaphylactic reaction to bee, wasp, or other insect stings, local anaesthetics, or other injected materials
3. If you have had allergy tests in the past, please fill in the following:
a. Skin tests (scratch or prick)
Positive to:
b. Patch tests
Positive to:
c. RAST or ELISA (blood tests)
Positive to:
d. Other (Please specify the name of the test)
Positive to:
4. Medications:
I take the following medications: (indicate dosage and frequency (how often you take the medicine). Include birth control pills.
I am allergic to the following medications:
I use the following inhalers ("puffers"):
5. I take the following food supplements; vitamin/mineral supplements; herbal; Naturopathic; Homeopathic remedies; on a regular basis:
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