PATIENT ALLERGY HISTORY FOR DR. A. MASTROSIMONE
Name
Date
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Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone
Please enter a valid phone number.
Email
example@example.com
Age
Gender
Please Select
Male
Female
Work or Best Contact Number
Please enter a valid phone number.
Main reason or symptoms for allergy consultation
How long have you had symptoms?
Which symptoms bother you the most?
Select all that apply: My Symptoms are worse in the:
Morning
Evening
Spring
Most of summer
Fall
Winter
Come and go all year
Not really sure
Are symptoms becoming worse each year?
Yes
No
About the same
List any medication or treatment that helped or relieved symptoms.
Were you ever tested for allergies?
Yes
No
If Yes how long ago?
Were allergy tests done on the: (Check)
Skin
Blood test
Other
Can you recall what you were allergic to? Check all you can recall
Pollen
Trees
Grass
Ragweed
Dust Mite
Mold
Dog
Cat
Were there any reactions to foods?
Yes
No
Which Foods?
You may also Scan or Attach Allergy-Testing results with this form.
Were you ever on allergy injections?
Yes
No
How long were you on allergy injections?
Did you have reactions while on allergy injections?
Yes
No
Were any of the reactions serious?
Yes
No
Were you given Adrenalin, Epinephrine or antihistamines after an injection?
Yes
No
Did allergy injections help or relieve allergy symptoms?
Yes
No
Partially
Why did you stop allergy shots? (Check)
Inconvenient
Painful
Reactions
Didn’t help
Other
Select or Check any of the following symptoms you have NOW or have had in the past
Eyes:
Itch
Redness
Tearing
Swelling
Do Eye Symptoms Appear:
All year
Spring
Summer
Fall
Winter
Do you use eye drops?
Yes
No
Occasionally
Do they relieve symptoms?
Yes
No
Partially
Nose:
Nasal Congestion
Runny/Drips
Both
How long have you had nasal symptoms? (Check all that apply)
Daily
Almost everyday
Worse in the morning
Worse at night
Indoors
Outdoors
Spring
Fall
Winter
Seasonal Changes
Snoring
Drippy
Sneezing
Nosebleeds
Other
My nasal congestion improves or is relieved by (Check all that apply):
Antihistamines
Decongestants(Sudafed)
Nasal steroids like Flonase/Nasonex/Other
Over the counter sprays like Afrin/Neosynephrine
Hot, steamy showers
Nothing really helps that much
Other
Do you have recurring sinus symptoms like pressure or pain?
Yes
No
Sometimes
How long have you had sinus problems?
How often do your sinus symptoms bother you? Check.
Daily
Few times a week
Times per month
Comes and goes all year
Worse in morning
More Frequent in: Winter / Spring / Fall (Weather Changes)
Some foods trigger headaches
Some foods trigger headaches If yes which ones?
Where is the pressure or pain located? (Check or Explain)
Above the eyes
Bridge of nose
Cheek areas
Comes and goes all year
Back of head
Topof head
Explain:
Do you become nauseous or vomit with your headaches?
Yes
No
Sometimes
Name of medication you use for headaches?
Do you use prescription headache medication?
Yes
No
Name of prescription medication:
Are your headaches relieved with medication?
Yes
No
Sometimes
Are antibiotics ever prescribed for your sinus problems?
Yes
No
Sometimes
If yes, how many times a year are antibiotics prescribed?
Did you have X-rays or CT-scan of your sinuses?
Yes
No
Were the X-rays/Ct scan?
Normal
Showed Infection
Polyps
Any sinus surgeries?
Yes
No
When
If Yes, did sinus surgery help
Yes
No
Not sure
Choose or check
EARS:
Feel blocked or full
Pressure
Infections
Dizziness
Postnasal drip or mucus in the throat:
Often
Occasional
Infrequent
Post nasal drip:
Worse in morning
Worse at night/lying down
About the same all year
Worse in winter
More during seasonal changes
Notice it more Indoors
Postnasal improves with
Antihistamine
Nasal sprays
Nothing helps
Hoarseness
Occasional
Most of the time
Slight or none
Frequent throat clearing
Constant
Intermittent
Annoys others
None
Frequent sore throats:
Yes
No
Antibiotics prescribed
Yes
Yes
No
How many times/yr.
blank
Mucus in my throat makes me cough
Cough
(Choose or select all that applies)
How long have you had a cough?
Do you smoke?
Yes
No
Is your cough getting:
Worse
About the Same
Getting Better
Mostly a dry cough_______ Worse lying down?
Yes
No
Same
Feels like mucus in my throat triggers coughing?
Bring up mucus that is;
Clear
Slightly cloudy
Thick/yellow
No mucus
Have you consulted a doctor about your cough?
Yes
No
Were antibiotics or cough medicine prescribed for your cough?
Yes
No
Did the medication help?
Yes
No
Slight Improvement
Have you tried over the counter cough medicine?
Yes
No
Slight Improvement
Doesn't help at all
If you had chest X-rays or a scan of your lungs were the results.
Negative
Bronchitis
Pneumonia
Do not recall
No chest X-rays or scans
Do you wheeze or get short of breath?
Yes
No
Sometimes
Coughing (check all that applies):
Occurs throughout the day
Worse in the morning
Worse at night
Worse with exercise
Worse when I lay down
Keeps me awake
Coughing attacks almost cause me to pass out
Mostly dry cough
I bring up mucus during coughing attacks
Do any of the following trigger or make your cough worse? (Check)
Postnasal drip
Dust
Foods
Pets -> Dogs/Cats
Exercise
Dampness/mildew or moldy odors
List other triggers of coughing you can think of?
Were you ever diagnosed as having Asthma?
Yes
No
When?
Do you use asthma medication?
Yes
No
Name of asthma medication(s)
Do you use inhalers for asthma or for your cough?
Yes
No
If YES which one and how often?
Do they help?
Yes
No
Sometimes
Approximately how many school or work days are lost as a result of your illness?
Few days
Few weeks
None
Do any of the following cause you to wake up during the night?
Wheezing
Shortness of breath
Postnasal drip and mucus in the throat
Cough
No I generally sleep through the night
If your answer was YES to any of the above. How often do you awaken?
Once a week Type option 1
Few times a monthType option 2
Few times a yearType option 3
Almost neverType option 4
List all medications you have taken or currently take for Asthma
Do your current asthma medications relieve your symptoms?
Yes
No
Partially
Were you ever hospitalized or seen in the emergency room because of asthma symptoms?
Yes
No
When
Were you ever seen in Emergency Room or Medical Facility for a Drug or Food Allergy?
Yes
No
If Yes. When did this occur?
What caused the reaction?
Have you experienced any of the following symptoms with foods or medication?
Skin rash
Hives
Shortness of breath
Cough
Wheezing
Fainting or passing out
Were you ever prescribed an Epipen?
Yes
No
If Yes do you carry Epipen with you?
Yes
No
Have you ever had to use an Epipen for a reaction?
Yes
No
One or more times
Within the past several years
Do you take an antihistamine for food or drug allergy symptoms?
Yes
No
Which one?
Benadryl
Other
Do you have any of the following? (Check all that apply)
Diabetes
High Blood Pressure
Blood disorders
History of heart attack or stroke
Hospitalizations for asthma or respiratory illness
HOME ENVIRONMENT
Do you live in a
Home
Apartment
Approximately how old is the home or apartment?
How long have you lived there?
If you have a basement is it damp, musty or moldy?
Yes
No
Dehumidifier in basement?
Yes
No
Basement finished?
Yes
No
Carpeting in Basement?
Yes
No
If basement is finished do you watch TV or spend time in the basement?
Yes
No
Do you have carpeting in the bedroom?
Yes
No
How old is the carpeting in the bedroom
How old is your mattress?
Is it encased?
Are there Dogs/Cats in the home?
Are there dogs or cats in the home?
Dog(s)
Cat(s)
Other
How many dogs?
How many cats?
Do pets sleep in bedroom?
Yes
No
Occasionally
Never
Do you have any symptoms when you are near or touch dogs or cats or any other animals?
Yes
No
Occasionally
Do you have any of the following symptoms after pet exposure?
Sneeze
Cough
Wheeze
Water Eyes
Skin Itch's
Rash or Hives
Do you take any medication or antihistamines if you have a reaction to pets?
Yes
No
Symptoms gradually disappear
If so what medication do you take
Antihistamine
Inhaler
Epipen
Please list all of your current medications:
Any additional comments you would like to mention that were not covered in the questionnaire
We do not support any claims to diagnose, treat, or cure any medical condition or disease.
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