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