TAAG Symptom Sheet

TAAG Symptom Sheet
Name

First NameLast Name
Date of Birth
Who Referred you to our practice?
Pharmacy
Pharmacy phone number

Area CodePhone Number
What brings you to our office?
Chief Complaints:

(Check the main symptoms)
Head or nose symptoms

SneezingNose blockingRunny nosePostnasal drainageSinus infectionsSore throatEar blockingHeadacheEye symptoms
Skin symptoms

HivesEczemaItching
Chest symptoms

CoughingWheezingChest infectionsShortness of breathHoarseness or loss of voice
GI

Acid refluxThroat clearingHeartburnHives
Other symptoms
List age when symptoms started for each category.
Head or nose symptoms
Chest symptoms
Skin symptoms

Include the pattern of symptoms:

	Head/nose	Chest	Skin
Year round, no seasonal variation
Year round, worse seasonally
Seasonal only

If seasonal symptoms, list months
Past Medical History
Allergic to any drugs (Penicillin, Aspirin, or any others)?

YesNo
If you are allergic please list which drugs.
List medications taken for allergies and asthma.
List any other medication (including over-the-counter drugs, creams, suppositories, etc.) taken with anyregularity:
Describe any reactions to foods:
Have there ever been allergic symptoms from the sting of a bee, wasp, yellow jacket, or hornet, other than localswelling at the site of the sting (symptoms such as generalized itching, hives, swelling in areas remote from thesting, hay fever, asthma, nausea, vomiting, difficulty breathing, etc.)?

YesNo
If so, give name, year and location of doctor doing the testing:
Have "allergy shots" been used previously?

YesNo
If so, for how long?
Do your symptoms increase from any of the following? Allergens:

Mowed grassDead grassDead leavesHayHouse dustCatsDogsFeathers
Do your symptoms increase from any of the following? Irritants:

SmokePerfumesSoapsDetergentsOutside dustPaintHairspray
Do your symptoms increase from any of the following? Weather Changes:

Windy daysTemperature/weather change
Other
Past Medical History, Other:
List surgeries or hospitalizations including nasal surgery / ear tubes / tonsillectomy / adenoidectomy:
When was your last flu shot?
When was your last TB skin test?
Do you have migraines?

YesNo
Describe any reactions to latex or rubber:
Pediatric patients only: Are your childhood shots up to date?

YesNo
Pediatric patients only: What was the child's birth weight?
Pediatric patients only: Were there any complications at birth?

Familly History: (check if family members have any of the following: )

	Mother	Father	Siblings	Children	Relatives
Asthma
Hay Fever
Sinusitis
Eczema

Do you have family members who are patients here at TAAG? If so, please provide his/her name.
Which doctor do they see?
Environmental History
What city do you live in?
How long have you lived there?
Previous locations?
What type of home do you live in?

HouseApartmentMobile Home
How old is your home?
How long have you lived in your current home?
Are you exposed to secondhand smoke?

YesNo
If yes, where?

HomeWorkOther
What kind of heat do you have?

CentralBaseboardPortable gas
What kind of air conditioning do you have?

CentralWindow unitNo air conditioning
How often do you change your air filters?
Please indicate if you use one or both of the devices.

HumidifierDehumidifier
Do you have a basement?

YesNo
Do you have a crawl space?

YesNo
Pets: Are there pets at home?

YesNo
If so, what kinds?
Where do your pets stay?

Outside completelyOutside some, inside someMostly inside
Bedroom: How old is your mattress?
Do you use a dust mite cover?

YesNo
What kind of pillow:

SyntheticFeather
What kind of Comforter:

SyntheticFeather
Type of flooring: Indicate all that apply

HardwoodTileCarpetLinoleum
Occupational/Social History
Occupation (if student, list school and grade):
Do you smoke?

YesNo
If yes, how many packs per day and for how long?
If you are a previous smoker, how many years did you smoke?
How many days of work or school missed per year due to allergies/asthma/sinusitis?
Do your symptoms change at work / with hobbies / with fume exposure? If so, explain.
If patient is a child, is the child in daycare or with a sitter?
If child is in daycare or with a sitter, how many days per week?
Review of Systems

Please check if you have/had problems related to the areas indicated.

CONSTITUTIONAL

	Yes	No
Weight Change
Fevers
Sweats
Fatigue

Eyes

	Yes	No
Glaucoma
Cataracts
Vision Surgery

EARS, NOSE, THROAT

	Yes	No
Loss of hearing
Dizziness
Hay fever
Sinus infections
Nose bleeding
Gum bleeding

RESPIRATORY

	Yes	NO
Chronic cough
Bronchitis
Shortness of breath
Asthma
Pneumonia

GASTROINTESTINAL

	Yes	No
Acid reflux/heartburn
Acid taste in mouth
Throat clearing
Blood in stool
Diarrhea
Constipation
Gall bladder disease

ENDOCRINE SYSTEM

	Yes	No
Diabetes
Thyroid problem
Hormone treatment

BREAST/GENITAL

	Yes	No
Menopause
Masses
Genital infections

URINARY SYSTEM

	Yes	No
Urinary tract
Bladder infections
Kidney stones
Incontinence
Trouble urinating
Prostate problems

Skin

	Yes	No
Cancers
Rashes

NEUROLOGIC

	Yes	No
Stroke
Seizures
Head injury
Nerve damage

PSYCHIATRIC

	Yes	No
Depression
Anxiety
Responsiveness

MUSCULOSKELETAL

	Yes	No
Osteoarthritis
Rheumatoid arthritis
Gout

HEMATOLOGIC

	Yes	No
Anemia
Enlarged lymph nodes
Easy bleeding

Other
The information provided in this form is true and complete to the best of my knowledge. to edit this text...
Signature

Clear
Date

MonthDayYear
Date
Form reviewed by physician.
Physician Signature

Clear
Should be Empty:

TAAG Symptom Sheet

Chief Complaints:

List age when symptoms started for each category.

Past Medical History

Past Medical History, Other:

Environmental History

Occupational/Social History

Review of Systems