Asthmaallergycentre.com

Initial Allergy Questionnaire and History
No Antihistamines for
1. Please prepare 3 days before your visit!
72 hours prior to
2. Complete this form before your visit and bring it Your Appointment is on:

DATE: _____________________
3. Skin testing is an important part of most Allergy evaluations. For this to be done, antihistamines will
TIME: ______________________
need to be stopped for 3 days before the visit.
Please call us for advice if you think stopping them WITH:  Jean Carney, MD
 Kuo Casey Chang, MD
antihistamines include:
 Austin Sargent, MD, PhD
MEDICATION
MEDICATION FOUND IN
 Andrea Moore, PA-C
 Anne Dahlkemper, PA-C
4. Asthma and other medication should not be
5. Over-the-counter cold or decongestant medications that are labeled as “non-drowsy” need not be Prescription nasal spray may be continued, with the exception of Astelin, Astepro and Patanase 6. Amitriptyline, nortriptyline, imipramine, trimipramine, and doxepin are medications that can interfere with skin testing, but we do not suggest stopping them since it’s not always safe to do so. Initial Allergy Questionnaire and History
Name: _____________________________________ Date: ______________________________________ Birth date: __________________, Age: ___________ Main reasons for the visit:
Others: _________________________________________________________________________ These symptoms started _______ years ago (or _____ months ago), at the age of _______________ Recurring or current symptoms:
None Mild Severe
None Mild Severe
Others: __________________________________________________________________________ What is the color of the nasal secretion, post-nasal drainage, or sputum?  clear  White  yellow  green  bloody  others: _________________________ By whom? _________________________________ What allergies were suggested by the tests? ________________________________________________ ___________________________________________________________________________________ From when to when? _________________________ When was the last one ________________________ When was the last one? ______________________ Number of emergency room visits for this problem in the past one year: ________ Has this condition required a stay in the hospital overnight?  Yes  No Number of work/school days missed due to this problem in the past one year: _____________ Does this condition interfere with sleep? Check the months during which you have symptoms:

None Mild Severe
None Mild Severe
Symptoms are improved by travel:
(for use by physician)
 Out of state ______, Where? _______________ Things you notice make the symptoms worse:
(for use by physician)
(Check all that apply)
 House cleaning  Making the bed  Lawn mowing  Raking leaves  Moldy or damp areas  Clear weather  Rainy weather  Being outdoor  Being indoor  Cool air  Warm air  Cat dander  Dog dander  Other animals ________________________  Smoke  Perfumes  Hair sprays  Soap powders  Laughing or crying  Exercise  Lying down  Getting up in the morning  Colds or flu  Aspirin, ibuprofen, Aleve  Type of reactions
Tobacco exposure:
Do you now smoke or use tobacco?  Yes  No
If no, did you smoke in the past?
If yes, how much? _____ packs per day, for _____ years, until _____ years ago. Does any other person who lives with you smoke? Who?______________________________ Does anyone smoke in the home?  Yes  No (continued next page) Environment:
(for use by physician)
Number of years living in this area: __________
In current home: _______________
Please list other areas lived in from birth to present:
_________________________________________
_________________________________________
_________________________________________
Home settings:
 Urban
Other pets: _________________________________ Other outside animals: ________________________ What pets are allowed in the bedroom? ___________ What pets had previously lived in your current home or may have left dander in your furniture? __________ ___________________________________________ ___________________________________________ Is a feather pillow or comforter used regularly? Watery damage or musty odor at home?  Yes  No Are there any basement living areas?  Yes  No More than 5 house plants? Work/School/Hobby exposures:
(for use by physician)
Are there more symptoms at work or school? Occupation: ________________________________ Known exposure at work:______________________ Do others at work have similar symptoms? Prior work exposure? ________________________ Exposures related to other activities/hobbies: _______ General medical review of systems:
 Unexplained weight gain or loss
 Frequent headaches
 Eye disease or recent vision changes
 Frequent sore throat
 Recurrent pneumonia
 Spitting up blood
 Lung diseases other than asthma
 Heart disease
 High blood pressure
 Foot/ankle swelling
 Need for more than one pillow to sleep
 Frequent heartburn or stomach indigestion
 Other current stomach or intestinal problems
 Liver disease
 Arthritis
 Seizure
 Skin disease or rashes
 Diabetes
 Tuberculosis
 Infection starting outside of U.S.A.
 Sinus or nasal surgery
 Tonsillectomy or adenoidectomy
 Indications of current pregnancy
 HIV infection
Other condition which might influence this evaluation: ____________________________________________ ____________________________________________ (continued next page) Family (genetic) history:
(for use by physician)
If you know of allergies in any of your BLOOD RELATIVES, show which relatives were affected: Medications:

Please list any medications (prescription, herbal, or over-the-counter) you have tried for the condition(s)
which prompted this visit.
_______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ _______________________ __________ _______________________ ______________________ Other comments or information you would like to bring to our attention:
___________________________________________________________________________________
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Source: http://www.asthmaallergycentre.com/files/Initial_allergy_questionnaire_and_history5.pdf