Irp-cdn.multiscreensite.com



Dr. Andrew D. Collins Patient (Parent) QuestionnairePatient’s Name: ________________________________ DOB: _____________ Date: ____________Referred By: _________________________ Primary Care Physician: ___________________Describe each problem that has led you to seek this allergy evaluation:____________________________________________________________________________________________________________________________________________________________________________________________________________Symptom History: Check any of the following symptoms that you had or have now:NOSE/THROAT/HEAD ______ Congestion ______ Runny nose ______ Postnasal drainage ______ Frequent sneezing ______ Frequent rubbing/itching of nose or throat______ Frequent sore throats ______ Nosebleeds ______ Frequent colds______ Sinus infections______Number of antibiotics prescribed in the last year: __________________Number of steroids prescribed in the last year: ___________ ______ Headaches______ Nausea and Vomiting with Headaches______ Frequency______ Triggers _______________________________________________________ Sensitivity to light______ Nasal polyps ______ Snoring______ Mouth breathing______ Bad breath______ Hoarseness______ Frequent Tonsillitis______ Enlargement of the Tonsils______ Have received allergy immunotherapy injections or "allergy shots"______ Do you take any oral allergy medications or nasal spray; if so which ones and how many days a week do you take them? _______________________________________________________________________EYES______ Redness ______ Itching or rubbing of eyes______ Watering ______ Swelling ______ Dark circles______ Dry eyes______ Do you use eye drops? If so, what eye drops do you use and how often do you use them? __________________________________________________________________________________________EARS______ Frequent infections______ Number of infections in past year ______________________ Fluid ______ Popping of ears______ Itching of ears______ Ear tubes______ How many sets of tubes and when were they placed? ___________________________________ Number of ear infections since last set of ear tubes ____________________ Hearing loss ______ Speech problems______ Dizziness(Vertigo)NECK/THROAT______ Thyroid enlargementCHEST ______ Frequent cough during the day; if so how many days of the week ____________ AM (when waking up) ______ PM (when going to bed) ______ All Day ______ Cough or shortness of breath in the middle of the night; if so, what symptoms ______; and how many night per month ____________ Shortness of breath; if so how many days per week ____________ Wheezing; if so how many days per week ____________ Exercise intolerance ______ Productive Mucous or Sputum ______ Pneumonia ______ How many times diagnosed with this? __________________ ______ Bronchitis ______ Frequent croup ______ History of asthma______ Do you use an inhaler? If so , what inhaler do you use and how many days per week do you use them? ______________________________________________________________________________________________GASTROINTESTINAL______ Pain with swallowing; if so with what specific foods ____________ Difficulty swallowing or food getting stuck; if so with what specific foods ____________ Frequent vomiting______ Frequent Diarrhea______ Abdominal Pain______ Heart burn______ Stomach Ulcers______ History of reflux______ Excessive belchingSKIN______ Eczema ______ Hives (welts) ______ Itching of skin______ Are there any specific triggers of your eczema, hives, or itching; if so what are the triggers ______________________________________________________________________________ Do you apply lotion, cream, or ointment to your skin; and if so, what kind and how often? __________________________________________________________________________ CARDIAC______ High Blood Pressure______ Name of Blood Pressure Medication _____________________________ Any other cardiac problem? __________________________________________Current Medications:Indicate the things below that make your symptoms worse.ExerciseBurning of Sugar CaneStrong OdorsSmokeDustChange in HumidityMorningPet DanderMold/MildewChange in TemperatureAfternoonFeathersPollenAlcoholEveningColds/Respiratory InfectionsHayOutside MedicationsFatiguePerfume/CologneInsideGrassStressEnvironmental History: What kind of house do you live in?_____ House_____ Apartment_____ Mobile HomeDo you have carpeting? Yes _____ No _____Do you have any pets?_____Cats_____Dogs_____Horses_____Other: List ________________If you have pets do they spend time in the bedroom; do they sleep in you or your child's bed? _________What is the approximate age of your home? ______________Is your mattress encased in a dust proof covering? Yes _____ No _____Is your pillow encased in a dust proof covering? Yes _____ No ______Do you have a moisture problem in your home? Yes _____ No _____What kind of air conditioning do you have?_____Central Air_____Window UnitsIs there anything unusual or remarkable about your home? Tobacco Smoke Exposure:Are there smokers in the home? Yes ______ No __________Do you smoke? Yes ________ No _________If yes: Cigarette __________ Pipe ___________ Chew ___________ Marijuana __________If yes, how much do you smoke in a day? __________How long have you smoked? _____________Food Reactions/IntolerancesDo you have any problems with any foods? Yes _____ No ______If so, what foods cause your problems? __________________________________________________________________________What kind of problems do you experience? List all that apply: Hives/Rashes/Stomach upset/Nausea/Vomiting/Bloating/Diarrhea/Life threatening event that required ER visit or hospitalization: Name of Food Type of Reaction to FoodWere you/your child ever prescribed an Epi-pen? Yes _______ No _________Are you on any special diet? Yes _____ No _____If yes what kind of diet? _______________________________Drug Allergies: Please list all drug allergies and describe your reaction to each one of them: hives/rashes/stomach problems/life threatening events that required ER visit or hospitalization. Name of Drug Type of ReactionInsect Allergy: Please list the reaction and describe your reaction to each one of them: hives/rashes/stomach problems/life threatening events that required ER visit or hospitalization.Name of Stinging Insect Type of ReactionMedical History Medical Diagnosis______________________________________________________________________________________________________ Hospitalizations______________________________________________________________________________________________________IF YOU HAVE HAD ANY ALLERGY TESTS OR LABS DONE PLEASE BRING RESULTS WITH YOU TO YOUR APPOINTMENT.Recent Labs? _____Yes _____No If yes what labs were done? When and where were they done? ____________________Recent X-rays? Chest or CT of Sinus or Chest _____Yes _____NoIf yes what was done? When and where were they done? _______________________________________Ever been allergy skin tested/allergy blood tested?If yes when and where were they done? _______________________________________History of allergy shots/allergy drops? _____Yes _____ NoIf so how long ago were they completed? __________________________Have you ever had a Pneumococcal vaccine? Yes _____ No _____When was your last Flu shot? ________________Have you ever had an immune workup done? Yes _____ No _____Factors affecting you or your child's symptoms: When are your symptoms worse?_______ Spring ______ Summer ______ Fall _____ WinterCHECK OFF ALL THAT APPLY:Family HistoryAllergiesFood AllergiesHives orSwelling of SkinAsthmaImmune DeficiencyAutoimmune diseaseMotherFatherBrothersSistersSocial History:Where do you work or go to school? __________________________________What is your work environment? _________________________________________________________________________________________Do you live near pollutants or industry? Yes _____ No _____ URTICARIA/HIVESSkip this section if this does not pertain to you.How long have you had hives? _______________________Is this the first time you have ever had hives? Yes _____ No _____If No indicate the last time you had hives: ___________________How often do you break out in hives? ________________Do they ever go away? Yes ______ No _______Where do you break out in hives? Arms/Legs/Abdomen/Feet/Hands/Face/All overHow long do the hives last? < 12 hours, < 24 hours, or several days? Do you know anything that triggers the hives? Yes _____ No _____If yes indicate what triggers the hives: _____________________________________________________________________________Do the hives itch? Yes ______ No _____Are the hives painful? Yes _____ No _____Do the hives leave bruises? Yes _____ No _____Have you had any associated swelling of lips, tongue, hands, feet, nausea, vomiting or stomach pain along with the hives? If yes circleall that apply.What medications have you tried for the hives and do they help? Name of MedicationHelpful or Not Helpful Have you ever gone to the emergency room for treatment? Yes _____ No _____If yes how many times? _________________________When was your last ER visit? _____________________Do you have any of these symptoms below? (check all that apply)Cold intoleranceConstipationWeight gainWeight lossFatigue? If so how long? _________________Joint/Muscle painHair lossMouth ulcersIs there a family history of Lupus/Rheumatoid Arthritis/Sjorgren'sHas any recent lab work been done since you have begun with the hives? Yes _____ No _____If yes when and where were they done? ___________________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download