• INITIAL ALLERGY EVALUATION

  • DOB:
     - -
  • Date:
     - -
  • Do you have symptoms or had symptoms, such as sneezing, watery nasal discharge, throat itching or dry mouth?
  • Do you have, or have ever had, frequent "colds," sinus problems or chronic nasal congestion including headaches?
  • Do your symptoms get worse in certain seasons or times of the day?
  • Are your symptoms worse around animals?
  • Do you have, or have ever had asthma, eczema, or hives?
  • Do you suspect that you have sensitivity to any type of food?
  • Do you snore or have any other problems with sleep?
  • Do you have a history of depression, anxiety, or other mood disorders?
  • Do you have or ever had chronic pain or swelling/inflammation?
  • Do you ever feel unusually elevated levels of psychological stress?
  • Do you feel psychological stress due to lack of sleep from allergies?
  • Have you ever experienced any PTSD symptoms?
  • Do you ever have problems with energy levels, mental sharpness, and productivity?
  • Do you ever find it hard to concentrate or control your behavior?
  • Have you ever had any symptoms related to eating disorders?

  • PATIENT QUESTIONNAIRE IV THERAPY

  • Health History

  • 1. Do you have a history of chronic illnesses?
  • 2. Have you ever been diagnosed with COVID-19?
  • 3. Have you ever experienced any of the following symptoms in the past 3 months? (Please check all that apply.)

  • Dehydration Symptoms

  • 1. How often do you drink water throughout the day?
  • 2. Have you experienced any of the following symptoms? (Please check all that apply.)

  • Chronic Fatigue

  • 1. On average, how many hours of sleep do you get per night?
  • 2. Do you wake up feeling refreshed?
  • 3. Do you experience excessive tiredness during the day, even after a full night's sleep?
  • 4. Do you find it difficult to perform daily activities due to lack of energy?

  • COVID-19 Long-Haul Symptoms

  • 1. Have you had any prolonged symptoms after recovering from COVID-10?
  • 2. Do you have any new or worsening symptoms since recovering from COVID-19?

  • Nutritional Deficiency Symptoms

  • 1. Do you follow a specific diet (e.g., vegetarian, vegan, keto, etc.)?
  • 2. Do you take any vitamin or mineral supplements regularly?
  • 3. Have you experienced any of the following symptoms recently? (Please check all that apply)

  • Additional Information

  • 1. Do you have any other health concerns or symptoms you would like to discuss?

  • FATIGUE SEVERITY SCALE (FSS)

  • The Fatigue Severity Scale (FSS) is a method of evaluating the impact of fatigue on you. The FSS is a short questionnaire that requires you to rate your level of fatigue.

    The FSS questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree that the statement applies to you.

    • A low value (e.g., 1) indicates strong disagreement with the statement, whereas a high value (e.g., 7) indicates strong agreement.
    • It is important that you circle a number (1 to 7) for every question.

  • FSS Questionnaire

    During the past week, I have found that:
  •

  • Scoring your results
    Now that you have completed the questionnaire, it is time to score your results and evaluate your level of fatigue. It's simple: Add all the numbers you circled to get your score.

    The Fatigue Severity Scale Key
    A total score of less than 36 suggests that you may not be suffering from fatigue. A total score of 35 or more suggests that you may need further evaluation by a physician.

    Your next steps
    This scale should not be used to make your own diagnosis. If your score is 36 or more, please share this information with your physician. Be sure to describe all your symptoms as clearly as possible to aid in your diagnosis and treatment.

  • Epworth Sleepiness Scale (ESS)

  • The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations.

    Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

    How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you. Use this scale to choose the most appropriate number for each situation:
    0 = would never doze
    1 = slight chance of dozing
    2 = moderate chance of dozing
    3 = high chance of dozing

     

    It is important that you select a number (0 to 3) on each of the questions.

  • Rows

  • Scoring your results
    Now that you have completed the questionnaire, it is time to score your results and evaluate your own level of daytime sleepiness. It's simple: Add all the numbers you circled to get your score.

    The Epworth Sleepiness Scale Key
    A total score of less than 10 suggests that you may not be suffering from excessive daytime sleepiness. A total score of 10 or more suggests that you may need further evaluation by a physician to determine the cause of excessive daytime sleepiness and whether you have an underlying sleep disorder.

    Your next steps
    This scale should not be used to make your own diagnosis. It is intended as a tool to help you identify your own level of daytime sleepiness, which is a symptom of many sleep disorders. If your score is 10 or more, please share this information with your physician. Be sure to describe all your symptoms, as clearly as possible, to aid in your diagnosis and treatment. It is important to remember that true excessive daytime sleepiness is almost always caused by an underlying medical condition that can be easily diagnosed and effectively treated.

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