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Allergy Questionnaire

Allergy Clinic Patient Questionnaire- NEW

Welcome to the Allergy Clinic.  Please answer the following questions so we may better assist you.
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What is your preferred method for learning

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Do you have a learning disability, language barrier, hearing/vision deficit?
Please select an option.
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How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?
Please select an option.
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PLEASE COMPLETE THE FOLLOWING INFORMATION: 

PAST MEDICAL HISTORY 

Asthma:
Please select an option.
Allergies:
Please select an option.
Eczema:
Please select an option.
Insect Allergy:
Please select an option.
Chronic/ Recurrent Hives/swelling:
Please select an option.
Autoimmune Disease:
Please select an option.
Immune deficiency:
Please select an option.
Heart Condition
Please select an option.
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** Additional details regarding allergic conditions will be asked on the back side**

PAST SURGICAL HISTORY- INCLUDE YR

Sinus Surgery
Please select an option.
Tonsil or Adenoidectomy
Please select an option.
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FAMILY HISTORY- INCLUDE WHAT RELATIVE(S)

Asthma:
Please select an option.
Allergies:
Please select an option.
Eczema:
Please select an option.
Latex Allergy:
Please select an option.
Insect Allergy:
Please select an option.
Chronic/ Recurrent Hives/swelling:
Please select an option.
Autoimmune Disease:
Please select an option.
Immune deficiency:
Please select an option.
Please complete this field.
MEDICATION ALLERGIES:
Please select an option.
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ALLERGY TO LATEX:
Please select an option.
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Tobacco Use?:
Please select an option.
Please complete this field.
Alcohol Use?
Please select an option.
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PLEASE LIST OR CIRCLE ALL OF YOUR CURRENT MEDICATION (INCLUDING OVER THE COUNTER):

Allergy medication:

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Respiratory Medications:

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**PLEASE SEE REVERSE SIDE FOR ALLERGY SPECIFIC SCREENING QUESTIONS** 

BREATHING CONCERNS
Please select an option.

Circle all respiratory diagnoses you have:

Symptoms:

Have you gone to the ER or urgent care in past year because of breathing issues?
Please select an option.
Have you ever been admitted to the hospital for breathing issues?
Please select an option.

What triggers your breathing symptoms?

ALLERGIES (INDOOR/OUTDOOR)
Please select an option.
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Circle all allergy symptoms you have:

Nasal symptoms:

Eye symptoms:

Breathing Symptoms:

What seasons do you have allergy symptoms:

What triggers your symptoms?

Where are you living:
Please select an option.
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Present in home:

Pets:

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Are pets allowed in bedroom:
Please select an option.
FOOD ALLERGIES:
Please select an option.
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What symptoms did you have when you ate the food?

Skin:

Nose/eyes:

Breathing:

Stomach:

Other:

ALLERGIES (INSECT)
Please select an option.
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What symptoms did you have when you were stung?

Skin:

Nose/eyes:

Breathing:

Stomach:

Other:

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REVIEW OF SYSTEMS – PLEASE CIRCLE IF YOU HAVE HAD ANY OF THE FOLLOWING IN THE LAST 4 WEEKS:

DO YOU HAVE A HISTORY OF RECURRENT INFECTIONS:
Please select an option.

PLEASE CIRCLE WHICH TYPE:

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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