Apmchiro.com - Allergy Form

Allergy History
Date

MonthDayYear
Date
Name
DOB

MonthDayYear
Date
Complaints

Please circle the appropriate number 0 to 3 according to severity

0 = Absent (no symptoms evident)	1 = Mild (Symptoms present, but minimal awareness)
2 = Moderate (tolerable)	3 = Severe

Nasal Discharge (runny nose)

0123
Nasal Obstruction (stuffy nose)

0123
Nasal Itching

0123
Sneezing

0123
Watery Eyes

0123
Itchy Eyes

0123
Gritty Feeling (eyes)

0123
Cough

0123
Wheezing

0123
Difficulty Breathing

0123
Headache

0123
Hives

0123
Eczema

0123
Itching Ears

0123
Sinus or ear infections

0123
Frequent colds or sore throat

0123
Sensitivity to pet hair

0123
Itchy throat

0123
Sinus Pressure

0123
Sinus Pain

0123
Other symptoms causing you problems?
Medications:

How often do you take medications for your allergy symptoms?

0 = Never	1 = Occasionally (several times a month or less)
2 = Frequently (several times a week)	3 = Daily

Antihistamines

0123
Oral Steroids

0123
Eye drops

0123
Nasal Steroids (Flonase, Nasacort)

0123
Asthma medication (Inhaler, Singulair, Advair)

0123
Other allergy-related medications
Does any medication give you complete relief of symptoms?
General Allergy History
How many months of the year do you have allergies?
How many years?
In what season are they worse (check all that apply)

SpringSummerFallWinter
Have you been allergy tested before?

YesNo
If yes, which type?

Skin prick/PunctureBlood Draw
Have you previously received

Allergy ShotsAllergy Drops
If yes (Allergy Shots), when?
If yes (Allergy Drops), when?
Do you smoke or use tobacco products?

NoYes, explain
List any animals you have in or around the home
Who else in your family has allergies?
PROVIDER ONLY

0-25 = MILD	26-50 = SIGNIFICANT
51-100 = SEVERE	100+ = VERY SEVERE

Raw Score
Score (Multiply Raw Score by 4)
This Allergy History worksheet is meant for use by a licensed medical professional only. This worksheet is in no way meant to confer a diagnosis or dictate a specific course of either testing or treatment in lieu of a medical professional's opinion. Scores and descriptions or severity are relative to questions asked and may not be seen in and of themselves as conveying medical advice or medical necessity.
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