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
Madeline Hoglund
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
PRIMARY CARE PROVIDER:
Patient's Preferred Name:
Briefly describe the main reason for your visit and what you hope to accomplish.
Condition
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
Have you ever had any of the following symptoms?
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
As sensation of choking or difficulty breathing air in
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
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
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
Asthma
Nose/Sinus/Eyes
Eczema
Hives
Comments
Animals (please name)
Pollens/molds/mildews
Respiratory infections, “Colds”
Exercise
Cold Air
Foods
Dust
Air Pollution
Fumes/Odors/Scents
Car/Truck Exhaust
Weather Changes
Aspirin/Aspirin like drugs (ie ibuprofen, naproxen)
Emotions/Stress
Hormone changes/ menstruation
Medications (please name)
Work- related (please name)
Previous Allergy Evaluation and Therapy *Please bring copies of results if possible
Yes or No
Dates
Allergy Skin Tests?
Allergy RAST Testing?
Allergy Injections?
Chest X-ray or CT scan?
Sinus X-ray or CT scan?
Have you ever needed sinus surgery?
Current Allergy Medications
Other Medications
Please list any Allergy Medications you have tried in the past.
Have you 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:
Yes or No
Date of last Vaccination
Are they up to date?
Have you received a Pneumovax?
Do you receive a yearly influenza vaccine?
Family History
Mother
Father
Sister
Brother
Maternal Grandparent
Paternal Grandparent
Other
Asthma
Hayfever
Eczema
Food Allergies
Hives
Cystic Fibrosis
Recurrent infections
Emphysema
Autoimmune diseases
Cancer
Heart Disease
Diabetes
Glaucoma
Other
Martial Status:
Occupational History: (please list most recent job first)
Has your illness affected your job performance? If yes, please explain
Do you have any hobbies that have potential exposures and/or affect your symptoms?
Do you or have you ever smoked cigarettes?
Tobacco Use
How Many:
Number of years:
Avg # of cigarettes/day:
Age Quit:
Current # of cigarettes/day:
Other tobacco use? Type? Amount?
Have you/do you have second hand smoke exposure?
Yes
No
Do you have a history of any other type drug use (ie marijuana, cocaine)?
Yes
No
If Yes, what type? Inhaled? IV?
Average amount of alcoholic beverages per week:
Environmental History
Yes Or No
Comments
Smokers in home?
Pets/Birds in home? What Kind?
Swamp Cooler?
Air conditioning?
Humidifier?
Heating? (type: forced air, electric, water)
Fireplace? (type: gas or wood burning)
Wood burning stove?
Smokers in home?
Pets/Birds in home? What?
Swamp Cooler?
Air conditioning?
Leaking roof or basement?
Mold or Mildew?
Located near a busy road?
Other:
Submit
Should be Empty: