Part 1. Symptoms



Name_________________________________ DOB ___________ Age _______Date_______________Chief Complaint (Why are you seeing the doctor?) ___________________________________________________________________________________________________________________________________________________________________________________________________________________Part 1. SymptomsEyes and EarsItchy & Watery EyesSwelling around EyesEar InfectionsRed EyesLight Hurts EyesDecreased HearingNose and SinusesStuffyDecreased SmellPost Nasal DrainageRunnyFrequent ColdsMouth BreathingItchyNosebleedsNose Spray UseSneezingNasal PolypsSinus HeadachesThroat and LungsSore ThroatWheezingLung InfectionsThroat InfectionsCoughingTonsillitisShortness of BreathSkinHivesEczemaSymptoms have been worse for___________________________________________________________Part 2. Variation of Symptoms.Do your symptoms occur: Daily3-4x a week1-2x a weekless than 1x weeklyDo you have trouble sleeping at night due to symptoms? YesNoOn the weekends, are your symptoms: BetterWorseNo DifferenceAre your symptoms worse during specific times of the day?MorningEveningBedtimeNo DifferenceAre your symptoms worse during any season?SpringSummerFallWinterCheck which month(s) in which nasal symptoms occur: Jan.Feb. Mar.April.May.Jun.Jul.Aug.Sept.Oct.Nov.DecCheck which month(s) in which eye symptoms occur: Jan.Feb. Mar.April.May.Jun.Jul.Aug.Sept.Oct.Nov.DecCheck which month(s) in which throat and lung symptoms occur: Jan.Feb. Mar.April.May.Jun.Jul.Aug.Sept.Oct.Nov.DecPart 3. Precipitation Factors.Which of these make your symptoms worse? Please Circle. Sweeping or dustingDogsDampness/HumidityVacuumingHorsesTemperature ChangesMaking the BedOther AnimalsHeatShaking RugsBirdsCold AirContact with Old FurnitureFeather PillowsDrafts/WindBasementCigarette SmokeExertionMowing GrassPerfumes/DeodorantLaughing/CoughingHay or StrawInsect SprayRespiratory InfectionsRaking LeavesPaintColdsCottages or CabinsHair SprayEmotional UpsetsMoldy or Musty AreasEnzyme DetergentsMensesCatsAir PollutionFatiguePart 4. Previous Allergy Evaluation and Treatment.Please check what applies to you.Have you had allergy skin tests or blood tests? YesNoDid the results of these tests indicate that you were allergic to: PollenDustDust MitesPetsMoldOthersHave you received allergy shots or immunotherapy? YesNoIf yes, when did you receive these shots or treatments? From age_______ until age _______.Was there any improvement in your symptoms after receiving injections? YesNoDid you have any bad reactions to allergy injections? YesNoIf yes, then please explain. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Part 5. Past Medical HistoryMedication ListMedication NameDoseTimes per DayAllergy and Asthma Medications used in the past_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please check what applies to you and explain what applies to you. Have you had any allergic reactions or any type of bad reactions to any medications? YesNoIf yes, which medications caused these reactions? _______________________________________________________________________________________________________________________________Do any foods or beverages bother you? (cause cramps, rash, swelling, itching, make other symptoms worse, etc.)YesNoIf yes, which foods or beverages cause these reactions? ____________________________________________________________________________________________________________________________Have you ever had a bad reaction to a bee, wasp, or yellow jacket sting? YesNoIf yes, then please explain. ____________________________________________________________________________________________________________________________________________________Other Medical IllnessesPlease list any medical illnesses or conditions that are not included in the previous sections. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SurgeriesPlease list any surgeries you have had. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HospitalizationsPlease list the reason for any hospitalizations you have had and their approximate date. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Part 6. Family HistoryPlease check what applies to each family member.AsthmaHay FeverEczemaHivesSinusMotherFatherBrotherSisterChildrenAuntUncleGrand MotherGrand FatherPart 7. Social HistoryPlease check what applies to you, and fill in the blanks where needed. What is your line of work?______________________________________Have you ever worked around:Rubber or LatexAsbestosMoldy Hay or GrainPigeons or ParakeetsPlastics/AcrylicsSteel MillBerylliumSand BlastingWelding ArcDetergent FactoryMeat WrappersSugar Cane FieldsA Mine or QuarryAre your symptoms worse at work? YesNoMarital Status: MarriedSingleDivorcedDo you now, or did you ever smoke? YesNoIf yes, how much and what did you smoke per day? ________________________________________________________________________________________________________________________________How many years did you smoke? _________Are you exposed to second hand smoke? YesNoIf yes, where? _________________________________________________________________________How much alcohol do you drink? _________________________________________________________What is your recreational drug use? _______________________________________________________Part 8. Environmental HistoryResidence TypeHouseApartmentOtherHold old is your present home? _______________In what area is your home located? UrbanSuburbanRuralHeavily WoodedIndustrialHeating SystemForced AirSteamHot WaterSpace HeaterElectric Radiant CoilsNone Air ConditioningNoneCentralRoomHumidifierNoneCentralRoomDoes you home have a basement? YesNoIf yes, is it musty smelling? YesNoHow many beds are in your bedroom? ___________________Mattress TypeInner SpringCotton FeltFeatherFoamPillow TypeFoamDacronCottonFeatherDo you have any of the following in your bedroom?BookcaseStuffed ToysUpholsteredFurniturePetsHouse PlantsBedroom Flooring TypeWall to Wall CarpetingHardwoodLinoleum/VinylPart 9. For Women of Childbearing AgeWhat is your birth control method? _______________________________________________________Are you Pregnant? YesNoYou plan a pregnancy in ____________________ yearsPart 10. Review of SystemsPlease check any symptoms or problems you have. Constitutional SymptomsFatiguePoor AppetiteWeaknessWeight LossWeight GainFeverChillsNight SweatsEyesCataractsBlurry VisionGlaucomaEye PainEars, Nose, Mouth, and ThroatEar-AchesRinging in EarsBroken NoseHoarsenessDecreased HearingSoreness inMouthNeck PainPulmonaryPneumoniaBronchitisCoughingBloodTuberculosisDate of last chest x-ray _______________CardiovascularChest PainHeart MurmurIrregular RhythmSwelling of LegsPalpitationsBlood ClotsHigh Blood PressureEasy BruisingHeart FailureGastrointestinalHeartburnAcid RegurgitationChokingDifficulty SwallowingRefluxHiatal HerniaUlcerDiarrheaLiver DiseaseNausea/VomitingGenitourinaryBladder InfectionsUrinal Tract InfectionsKidney TroubleYeast InfectionsMenstrualAbnormalitiesEndocrineDiabetesThyroid DiseaseHeat IntoleranceMusculoskeletalJoint PainMuscle PainBack PainArthritis/GoutOsteoporosisSkin and/or BreastRashesSwellingInfectionsAthlete’s FootVaricose VeinsNeurologicalHeadachesDizzinessVertigoNumbnessSeizuresWeakness of LimbsPsychiatricDepressionAnxietyMood SwingsTrouble SleepingStressAllergic/ImmunologicHay FeverAsthmaSinus InfectionsFood AllergiesFrequent InfectionsPlease have your primary care doctor fax or send recent blood tests and x-ray results to our office. Add any additional comments you would like to make regarding your problem.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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