Medical History

Referred By :

Reason for seeing allergist, please list symptoms:

How long have you had those symptoms?

Does anything worsen or improve your symptoms (describe)?

Medications and treatments you've tried?

Have you had any Diagnostic tests, labs or pulmonary breathing tests related to these symptoms? Yes No

If yes, please describe what when & where they were done

Drug Allergy:

Name of Drug :

What was the reaction?

Approximate date of reaction?

Current Medications:

(list all medications, including those you buy/use without a prescript ion and any herbal/vitamins suppliments)

Medication	Dosage	Times per day

Do you have a history of?

Other Medical Issue:

List other illnesses that you are being treated for:

Have you been tested for allergies (when)?

Have you been on allergy shots (when & for how long) ?

Have you ever had a reaction to foods? Yes No

If yes, please explain what food and what type of reaction:

Have you ever had a reaction to stinging insect? Yes No

If yes, please explain what insect and what type of reaction:

Any surgeries or hospitalizations in the past? Yes No

If yes, what, when & where:

All patients answer the following

When was your last influenza vaccine?

Review of Systems
GENERAL:

Anxious	Weight Loss/Gain
Depressed	Wired
Fatigued	Lack of Interest
Sense of Hopelessness

HEAD/NEUROLOGICAL:

Dizziness	Loss of Sensation/Touch
Headache (Sinus)	Memory Loss
Headache (Tension)	Migraines
Headache (Undefined)	Tremors
Incoordination

EYES:

Burning	Itching
Dark Circles	Pain
Double Vision	Swollen Eyelids
Dry	Tearing

EARS:

Itchy	Pressure
Painful	Ringing
Popping

NOSE:

Clear Discharge	Poor Smell
Colored Discharge	Post-Nasal Drip
Facial Pain	Sneeze
Itchy	Snorer
Nose Bleeds	Stuffed/Congested
Painful

MOUTH/THROAT:

Bad Taste	Hoarseness
Bad Breath	Itchy
Difficult to Swallow	Mouth-Breather
Dry	Tooth Pain
Frequent Infections

ENDOCRINE:

Excessive Sweating	Often Cold/Hot
Large Thyroid/Goiter	Thyroid Problems

NECK/HEMATOLOGIC:

Bleeding Disorder	Tender Nodes
Easy Bruising	Unusual Growth
Hemophilia

CARDIOVASCULAR:

Chest Burning	Racing Heart
High Blood Pressure

RESPIRATORY:

Cough	Shortness of Breath with Exercise
Heavy Feeling	Tight Feeling with Exercise
Produce Phlegm	Wheeze
Shortness of Breath at Rest

GASTROINTESTINAL:

Abdominal Pain	Food Intolerance
Bloating	Heartburn
Change in Appetite	Nausea
Constipation	Vomiting
Diarrhea

GENITOURINARY:

Burning Urination	Frequent Urination
Discharge	Incontinence

MUSCULOSKELETAL:

Arthritis	Sore Joints
Back Pain	Swollen Joints
Gout	Weakness of Arms or Legs

SKIN:

Burning	Itching
Dry Skin	Rash
Hives	Swelling

Family History:
Do any of your relatives have a history of the following diseases? If so please specify the relationship. Or Are you adopted?

Social History:

Are you exposed to smoke? Yes No

Who smokes?

Are you currently: Smoker? Yes No

If Yes, What year did you begin smoking?

If Yes, How many packs a day?

Ex-smoker? Yes No

What month & year did you quit smoking?

How many years did you smoke?

Do you chew Tobacco? Yes No

What is your occupation and work place?

How often do you exercise?

Do you drink alcohol? Yes No

If yes, how often:

How much:

Do you use recreational drugs? Yes No

Environmental History:

Do you have pets? Yes No

If yes, what kind and how many of each?

Are you exposed to any other animals on a daily basis? Yes No

If yes what kind?

Do you use a down or feather comforter or pillow? Yes No

Do you use Dust Mite covers: Pillows Mattress

Is there carpeting in your home? Yes No

Do you have any mildew/mold in your home? Yes No

Any roaches/rodents? Yes No

Approximately, what year was your home/apt built?

Any other exposures you feel we may need to be made aware of ?

Allergies affecting Nose	Ear Infections
Allergies affecting Eyes	Eczema
Acid Reflux	Emphysema
Arrhythmias	Headache
Asthma	Hives
Bronchitis	Hypertension
Colitis	Pneumonia
Chemical Dermatitis	Sinusitis
COPD	Sleep Apnea
Coronary Artery Disease	CPAP user

Disease	Relationship (Parent, Sibling, Child)
Allergies
Asthma
Colitis
Coronary Artery Disease
Diabetes
Eczema
Emphysema
Food Allergies
Hives
Hypertension
Migraines
Sinusitis
Sleep Apnea
Swelling Disorder
Thyroid Disease
Other