PATIENT ALLERGY HISTORY FOR DR. A. MASTROSIMONE

PATIENT ALLERGY HISTORY FOR DR. A. MASTROSIMONE
Name
Date

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
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.
Email
example@example.com
Signature

Clear
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

PATIENT ALLERGY HISTORY FOR DR. A. MASTROSIMONE

You may also Scan or Attach Allergy-Testing results with this form.

Select or Check any of the following symptoms you have NOW or have had in the past

Choose or check

Cough

HOME ENVIRONMENT

We do not support any claims to diagnose, treat, or cure any medical condition or disease.