Advanced Allergy & Asthma Associates

Advanced Allergy & Asthma Associates

C/Food Allergy Center of Illinois Medical Update
Name

First Name Last Name
Date

Month Day Year
Date
Your Pharmacy:
Primary Care Physician:
Your Insurance/ID info:
Please email new card as of this year to: info@myallergydr.com
REQUIRED:
WHAT ARE YOUR CONCERNED ABOUT:
PLEASE CHECK OFF EACH SYMPTOMS YOU HAVE OR CHECK OFF NONE:
General

Anxious Depressed Fatigued Lack of interest Sense of hopelessness Weight loss/gain Wired None
Head/Neurological

Dizziness Headaches (Migraines, Tension,Sinus, Undefined) Incoordination Loss of sensation/touch Memory loss Tremors None
Eyes

Burning Dark Circles Double Vision Dry Itching Pain Swollen Eyelids Tearing None
Ears

Itchy Painful Popping Pressure Ringing Left ear is affected Ringing Right ear is affected None
Nose

Stuffed/Congested Clear Discharge Colored Discharge Facial Pain Itchy Nose Bleed Painful Poor Smell Post-Nasal Drip Snorer None
Mouth Throat

Difficult to swallow Dry Bad Taste Frequent Infections Hoarseness Itchy Bad Breath Tooth Pain Mouth Breather None
Endocrine

Often Cold/Hot Excessive Sweating Thyroid Problems Large Thyroid/Goiter None
Neck/Hematologic

Tender Nodes Unusual Growth Hemophilia, Bleeding Disorder Easy Bruising None
Cardiovascular

Chest Burning Racing Heart High Blood Pressure None
Respiratory

Cough Wheeze Produce Phlegm Heavy feeling Tight feeling with exercise Short of Breath ( at rest or with exercise) None
Gastrointestinal

Abdominal Pain Bloating Change in Appetite Constipation Diarrhea Food Intolerance Heartburn Nausea Vomiting None
Genitourinary

Frequent Urination Burning Urination Incontinence Discharge None
Musculoskeletal

Weakness of Arms and Legs Sore Joints Swollen Joints Back Pain Gout Arthritis None
Skin

Rash Itching Swelling Burning Dry Skin Hives None
Since Last Visit please enter any new diagnosis, surgeries, treatments, ER visits:
List Current Medications: Name,Dosages & use (once daily, twice daily, as needed)
IF you are Asthmatic or have any inhaler to use as needed please answer the following :
1. In the past 4 weeks,how much of the time did breathing issues or asthma keep you from getting as much done at work, school, or at home?

A. All of the time B. Most of the time C. Some of the time D. A little of the time E. None of the time
2. During the past 4weeks, how often have you had shortness of breath or coughing?

A. More than once a day B. Once a day C. 3 to 6 times a week D. Once or twice a week E. Not at all
3. During the past 4 weeks, how often did breathing symptoms (wheezing, short of breath, chest tightness with cough or pain) wake you up at night or earlier than usual in the morning?

A. 4 or more nights a week B. 2 or 3 nights a week C. Once a week D. Once or twice E. Not at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol ie Proair, Ventolin, Proventil)?

A. 3 or more times per day B. 1 or 2 times per day C. 2 or 3 times per week D. Once a week or less E. Not at all
5. How would you rate your breathing or asthma control during the past 4 weeks?

A. Not controlled at all B. Poorly controlled C. Somewhat controlled D. Well controlled
Should be Empty:

Advanced Allergy & Asthma Associates

PLEASE CHECK OFF EACH SYMPTOMS YOU HAVE OR CHECK OFF NONE:

IF you are Asthmatic or have any inhaler to use as needed please answer the following :