Advanced Allergy Associates

 

 

ADVANCED ALLERGY ASSOCIATES

PATIENT MEDICAL HISTORY QUESTIONNAIRE (ALLERGY)

 

Patient Name: _________________________________Today’s Date: _________________________

 

Sex: ______ Date of birth: ____________________ Age: ____ Referred by: _____________________

 

Pharmacy of choice: _________________________ Phone#: _________________________________

 

Primary Care Doctor: _______________________________  Doctor Phone#: ___________________

 

Reason for your visit:________________________________________________________________

 

Describe the most distressing symptoms caused by your medical problem:

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When did symptoms begin?________________ How often they occur?___________________
Worse at night or day?_________How long do symptoms last? (hours, days, etc.)____________
Circle seasonal pattern:           Spring              Summer           Fall      Winter             ALL YEAR

 

What relieves symptoms or causes them to go away?___________________________________

 

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What makes the symptoms worse? ________________________________________________________________________________

List all medications you have tried in the past to relieve these symptoms and the response you have had to each (including over the counter medications):

Medication

Relief

No Relief

Side Effects

 

 

All current medications (including allergy medications, nutritional supplements, vitamins, herbals): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you taken any allergy medications within the last 7 days? Yes / No

If yes, which one(s) and dosage(s): ________________________________________________

 

Known Allergies (circle all that apply):

Allergy to foods: Milk, cheese, eggs, fish, shellfish, nuts, peanuts, vegetables, melon, strawberries, wheat, rice, soy, other:_________________

Allergy to: X-Ray Dye: Yes / No              Latex (balloons, condoms…): Yes / No

Allergy to medications (which):__________________________________________________

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Past Medical History:       Do you have any pain? Yes / No  Pain Scale: (0=none; 10=intense) ___/10

Have you ever had any:  Allergy skin test? Yes / No  Allergy Blood Test?  Yes / No  

Date of testing: _______________________ Physician’s name: ________________________ Have you ever been on allergy shots? Yes / No Date(s): ______________________________

 

Do you have asthma? Yes / No                                

            symptoms: ____more than 2X/week   __occasional  ____shortness of breath __season change

       ____night cough ___problems exercising 

Do you have frequent infections (sinus, lungs, bacterial)? Yes / No

Have you had a sinus infection? Yes / No   If yes, how often per year: ____________________

Have you ever had a sinus X-ray or CT? Yes / No Date(s): ____________________________

 

Have you been stung by an insect (bee/wasp/hornet/yellow jacket)? Yes / No  Reaction: ___________

Do you have Skin Problems: Eczema,  Hives, ________ ? Seen by a Dermatologist? Y/N

 

Other Medical Problems: ________________________________________________________

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History of Surgeries / Year _____________________________________________________

 

            ____________________________________________________________________________

 

Social/Environmental History:

Do you live in a house or apartment? _________   How old is the home: ___ years old 

How long have you lived in New Orleans? ____________________________________

How long have you lived in your current home? _____ Is there any obvious mold problem? Y / N

Heat: Forced hot air / Gas / Oil / Radiator / Electric        Air Conditioning: Central / Window

Type of floor in your bedroom: Carpeting / Hard wood / Tile / Other: _________

Type of bedding:  Comforter: down/synthetic    Pillow: feather/synthetic/polyester

Pets: Dog  Cat  Other:____________________________________________________

History of smoking: Yes / No How long? ____________ Packs per day: __________________ Prolonged cigarette smoke exposure (“second hand smoke”): Yes / No

Do you drink alcohol? Yes / No  How often? _________________________  Drugs: ________

 

 

 

Please list anything not discussed in this questionnaire that you consider important to share with your doctor: (all responses are confidential)

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