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Appendix 1 - patient-physician allergy questionnairre

Allergy & Asthma of Illinois  6615 N. Big Hollow Rd., Peoria, Illinois 61615  309-691-5200 Appendix 1 - New Patient Allergy History
Name _________________________________________ Age ___________ Birthdate ______________ Family doctor ___________________________________ 1. Present illness:
a. Briefly, what are your most prominent symptoms?
_________________________________________________________________________________________________ _________________________________________________________________________________________________ b. When did they start? ______________________________ How frequent are they? _______________________ c. Are they present all year round (to any degree)? ___________________________ d. Circle the months that are especially bad: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec e. Approximately how many days of school or work are missed per year? ___________________________ f. How often are you treated with antibiotics for sinus or chest infections? ___________________________ g. Have you ever seen an allergist before? Yes / No Been skin tested? Yes / No On allergy shots? Yes / No h. Have you ever had sinus surgery? Yes / No 2. Circle any of the following that make your symptoms worse:
being indoors being outdoors weather changes exercise smoke
mowing lawn playing in / on grass raking leaves other : _________________________________ 3. Circle any of the following that you have had in RECENT months:
Nose/Sinuses

Emotions
4. Have you ever been diagnosed with asthma or “reactive airways” or treated with inhalers?
a. How old were you when your asthma began? __________
b. How often (per day or week) do you use an inhaler such as albuterol (Proventil, Ventolin) or Maxair? _____________
c. How often do you have wheeze, shortness of breath, cough, or chest tightness? _______________________________
d. Do asthma symptoms ever awaken you at night? _______
e. Has asthma interfered with your work, social or physical activities? ________________________________________
f. Have you been treated with oral steroids (prednisone, Medrol) in the past year? __________ How often? _________
g. Have you ever needed ER visits or hospitalization? ________ How often? _________________________________
h. Do you have a peak flow meter? ________ “Typical” reading? ___________ “Best” reading? _____________
5. Are there any foods that cause symptoms? Yes / No Specify and explain symptoms: _____________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
6. If you have had any recent studies, please specify with approximate date and result:
a. Chest X-ray: _________________________________________________________________________________
b. Sinus CAT scan or X-ray: ______________________________________________________________________
c. Labs: _______________________________________________________________________________________
TURN OVER  AAI, 2000 – revised 10/05
7. Stinging insects: Any reactions to stinging insects (bees, wasps, etc)?
Did reaction go beyond area of sting itself? __________________________________________________________ 8. Females: Are you pregnant? yes no
9. List other medical diagnoses:
9. List all medications and doses (include over-the-ctr):
10. Are you allergic to any medications (such as antibiotics)? Yes / No Please list meds and reaction:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
11. Social history:
a. Occupation? ______________________
Hobbies or activities? ________________________________________ b. Work exposures? _________________________________________________________________________________ c. Have you ever smoked? Yes / No If so, packs / day: ________ Years smoked: ________ Quit: ______ If so, how much? ________________________________
12. Family history:

a. Circle if you have family history: Asthma Hayfever Sinus problems Migraines Other allergies ____________
b. Other illnesses in your family (list):
Father _________________________________ Children ___________________________________ Grandparents ____________________________ How many children do you have? _______________ 13. Pets
Do you have pets? Yes / No
If so, what ? _____________________________________ Are you exposed to any other animals? Yes / No If so, what & where? _________________________________ 14. Environmental history
a. House , apartment or mobile home ? _____________________
b. How long have you lived there ? ___________________ c. Is there a basement ? Yes / No d. Is there mold or mildew growing anywhere in your home? Yes / No Houseplants ? Many / Few e. Do you run? : humidifier dehumidifier air cleaners (type: _____________________________) f. Mattress: Standard mattress Water-bed Foam Futon g. Is your mattress and pillow covered with a plastic or dust mite-proof zipper cover ? Yes / No If not, flooring is _________________________ i. Does anyone in your home smoke? Yes / No If so, who? _____________________________ j. Have you seen cockroaches in your home in the past 3-4 months? Yes / No 15. Additional comments: ______________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Source: http://allergyandasthmaofillinois.net/Patient%20-%20Allergy%20History%20Dec%2008.pdf

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PF-03 /PF-04 Print head Warranty Claim Form Please complete this form and together with your print head return to the address printed on page 3. Please ensure you return al the required information as specified in the Print head Warranty Claim Returns Checklist on page 2 of this form. Failure to do may mean that your claim cannot be processed. Alternatively Avantech Limited can

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