Pediatric Allergy New Patient Questionnaire
DEPARTMENT OF ALLERGY
Very Important: Please complete the following questionnaire, as it is pertinent to the individual being evaluated. Completion of this form will assist us in evaluating and treating your allergy problem. Failure to do so may result in asking you to reschedule this appointment. Thank you.
Please select a provider:
*
Please Select
Dr. Karen Andrews
Dr. Katie McCormack
Hallie OBranovic, NP-C
Lauren Rosso, PA
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PRIMARY CARE PROVIDER:
Referring Provider
Patient's Preferred Name:
Briefly describe the main reason for your visit and what you hope to accomplish.
Conditions: Has your child ever had any of the following problems?
Rows
Yes / No / Unsure
Age at Onset
Comments
Asthma (Wheezing)
Yes
No
Other Breathing problems (cough, shortness of breath, frequent “chest colds”)
Yes
No
Sinus infections
Yes
No
Nasal Polyps
Yes
No
Hay fever (runny/stuffy/itchy nose)
Yes
No
Hives or swelling
Yes
No
Eczema
Yes
No
Reactions to Foods (please list)
Yes
No
Reactions to Drugs (please list)
Yes
No
Reactions to Insect Stings
Yes
No
Has your child ever had any of the following symptoms?
Rows
Yes or No
How many days in the last month
Severity
Worst Season
Comments
Runny or stuffy nose
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Itchy nose
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Sneezing
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Eyes: itching, watery
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Wheezing
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Coughing
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Wheezing or cough with exercise
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Night time awakenings due to shortness of breath or cough
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Turning blue due to shortness of breath
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Skin problems
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Chest tightness
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Snoring
Yes
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Mild
Moderate
Severe
Spring
Summer
Fall
Winter
Exacerbating Factors (Triggers) - Check all that apply
Rows
Asthma
Nose/Sinus/Eyes
Eczema
Hives
Comments
Animals (please name)
Yes
No
Yes
No
Yes
No
Yes
No
Pollens/molds/mildews
Yes
No
Yes
No
Yes
No
Yes
No
Respiratory infections, “Colds”
Yes
No
Yes
No
Yes
No
Yes
No
Exercise
Yes
No
Yes
No
Yes
No
Yes
No
Cold Air
Yes
No
Yes
No
Yes
No
Yes
No
Foods
Yes
No
Yes
No
Yes
No
Yes
No
Dust
Yes
No
Yes
No
Yes
No
Yes
No
Air Pollution
Yes
No
Yes
No
Yes
No
Yes
No
Fumes/Odors/Scents
Yes
No
Yes
No
Yes
No
Yes
No
Car/Truck Exhaust
Yes
No
Yes
No
Yes
No
Yes
No
Weather Changes
Yes
No
Yes
No
Yes
No
Yes
No
Aspirin/Aspirin like drugs (ie ibuprofen, naproxen)
Yes
No
Yes
No
Yes
No
Yes
No
Emotions/Stress
Yes
No
Yes
No
Yes
No
Yes
No
Hormone changes/ menstruation
Yes
No
Yes
No
Yes
No
Yes
No
Medications (please name)
Yes
No
Yes
No
Yes
No
Yes
No
Work- related (please name)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Previous Allergy Evaluation and Therapy *Please bring copies of results if possible
Rows
Yes or No
Dates
Allergy Skin Tests?
Yes
No
Allergy RAST Testing?
Yes
No
Allergy Injections?
Yes
No
Chest X-ray or CT scan?
Yes
No
Sinus X-ray or CT scan?
Yes
No
Have you ever needed sinus surgery?
Yes
No
Yes
No
Current Allergy Medications
Other Medications
Please list any Allergy Medications your child may have tried in the past.
Has your child ever needed to take Oral Steroids for an allergic condition? (for example prednisone, dexamethasone)
Past Medical History: Please list any other illnesses or chronic medical conditions you have had.
Please list all hospitalizations/surgeries: Please give reason and date
Immunizations:
Rows
Yes or No
Date of last Vaccination
Are they up to date?
Yes
No
Have you received a Pneumovax?
Yes
No
Do you receive a yearly influenza vaccine?
Yes
No
Family History
Rows
Mother
Father
Sister
Brother
Maternal Grandparent
Paternal Grandparent
Other
Asthma
Yes
Yes
Yes
Yes
Yes
Yes
Hayfever
Yes
Yes
Yes
Yes
Yes
Yes
Eczema
Yes
Yes
Yes
Yes
Yes
Yes
Food Allergies
Yes
Yes
Yes
Yes
Yes
Yes
Hives
Yes
Yes
Yes
Yes
Yes
Yes
Cystic Fibrosis
Yes
Yes
Yes
Yes
Yes
Yes
Recurrent infections
Yes
Yes
Yes
Yes
Yes
Yes
Emphysema
Yes
Yes
Yes
Yes
Yes
Yes
Autoimmune diseases
Yes
Yes
Yes
Yes
Yes
Yes
Cancer
Yes
Yes
Yes
Yes
Yes
Yes
Heart Disease
Yes
Yes
Yes
Yes
Yes
Yes
Diabetes
Yes
Yes
Yes
Yes
Yes
Yes
Glaucoma
Yes
Yes
Yes
Yes
Yes
Yes
Other
Yes
Yes
Yes
Yes
Yes
Yes
Environmental History
Rows
Yes Or No
Comments
Smokers in home?
Yes
No
Pets/Birds in home? What Kind?
Yes
No
Swamp Cooler?
Yes
No
Air conditioning?
Yes
No
Humidifier?
Yes
No
Heating? (type: forced air, electric, water)
Yes
No
Fireplace? (type: gas or wood burning)
Yes
No
Wood burning stove?
Yes
No
Leaking roof or basement?
Yes
No
Mold or Mildew?
Yes
No
Located near a busy road?
Yes
No
Other:
Yes
No
Birth History
Rows
Please respond
Place of birth (city/state):
Length of pregnancy:
Type of delivery:
Complications:
Developmental concerns:
Diet History
Rows
Please respond
Breast fed? If so until what age?
Type of formula used:
Age at which solids were introduced:
Are any foods currently avoided:
Submit
Should be Empty: