stcacupuncture.com - Allergy Questionnaire

Allergy Questionnaire
Patient Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender:
Home#:
Please enter a valid phone number.Format: (000) 000-0000.
Work#:
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Physician:
Referring Physician:
Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand:
- We do not treat symptoms or diseases.
- Allergy is not a disease, rather a condition.
- A symptom is an attempt by your body to tell you something.
- We will attempt to find the underlying cause.
- We do not use drugs in this program.
- There is no single “healthy” diet that will work for everyone.
- Just because food is considered “healthy”, does not mean it is “healthy” for you.
- Your diet consists of everything you eat, drink, rub on your skin, or inhale.
- Our procedures are safe and painless.
Briefly describe the reason for your visit and what you hope to accomplish:
AGE WHEN SYMPTOMS WERE FIRST OBSERVED
DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?
HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?
PREVIOUS DIAGNOSIS OF ALLERGY
FAMILY MEMBERS WITH ALLERGIC SYMPTOMS
FREQUENCY & SEVERITY OF ALLERGY SYMPTOMS
SYMPTOMS ARE WORSE
SYMPTOMS ARE BETTER
What makes you feel better?
ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURE

Other
FOOD RELATED SYMPTOMS
FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE
CHEMICALS THAT CAUSE SYMPTOMS

Other:
WHEN ARE YOUR SYMPTOMS WORSE
MEDICATIONS
Do you take any of the following medications on a regular basis?
Please list any medications that you are currently taking:
SMOKING
Do you presently smoke?
If yes, average number of cigarettes per day
Does anyone smoke in your home?
PREVIOUS ALLERGY EVALUTION
Have you ever seen an allergist?
Have you had allergy skin testing?
Did you have any positive reaction?
If yes, please list positive allergens (include any medications)
Have you ever received allergy injections?
WORK ENVIRONMENT
What is your occupation?
Are you exposed to chemicals or strong odors at work?
If yes, briefly explain
Are you symptoms worse while at work?
If yes, briefly explain
ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW?
ANYTHING ELSE YOU WOULD LIKE TO ASK?
Should be Empty:

Allergy Questionnaire

MEDICATIONS

SMOKING

PREVIOUS ALLERGY EVALUTION

WORK ENVIRONMENT