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
Submit
Should be Empty: