ABC Pediatrics Allergy Questionnaire

ABC Pediatrics' Allergy Questionnaire

This form must be filled out for new allergy referral patients.
Patient Name

First Name Last Name
Contact Number

Area Code Phone Number
Birth Date

Month Day Year
Which provider at ABC do you normally request or see?
Does the patient suffer from allergies?

Yes No
Does the patient take allergy medications?

Yes No
In the last year, check any of the medications that the patient has taken.

Benadryl Nasal Sprays Visine Claritin Skin Creams Xyzal Inhaler Steroids Zyrtec
Does the patient experience any of these symptoms? If so, check them off and please explain how often in the area provided below.

Watery Eyes Itchy Eyes Red Eyes Runny Nose Stuffy Nose Itchy Nose Frequent Sneezing Post nasal drip Chronic/Seasonal Colds Sinus Pressure/Sinus Headaches Dry, Red or Itchy Skin Consistent Coughing Asthma Itchy Mouth/ Throat Clearing Restless Sleep/Snoring Daytime Fatigue Dark Circles around eyes
Explain how often the patient experiences selected symptoms here:
Has the patient ever had a severe anaphylactic reaction (severe allergic reaction) that required emergency medical attention?

Yes No
If YES, Please describe what happened:
Has the patient ever been diagnosed as a moderate or severe asthmatic?

Yes No
Is the patient taking blood pressure medications?

Yes No
Has the patient ever had a reaction to any foods?

Yes No
If yes, please describe the event:
Has the patient ever been tested for food allergies?

Yes No
Signature

Clear
Do not fill anything else out past this point! The information below is for ABC Pediatrics and your provider's use only.
As the patient’s PCP, I am recommending that my patient proceed with Percutaneous (Skin Prick) Allergy Testing. * In Office Use Only

Yes No
Primary Care Provider’s Signature- *In Office Use Only
Should be Empty:

ABC Pediatrics' Allergy Questionnaire