Paul R. Young, M.D. PLLC | ALLERGY HISTORY QUESTIONNAIRE

Today’s Date:

GENERAL INFORMATION

First Name:


MI:

Last Name:

Social Security Number:


Date of Birth:


Address 1:

Address 2:

City:

State:

Zipcode:

Phone Numbers

Home:

Cell:

Work:


If we need to contact you, which is the preferred number?



Can we leave a message at this number on the answering machine?



Are there other members of the household that we may leave the message with regarding your health matters?




If so whom?


E-mail address (Required Field)



Occupation:

Employer:

Preferred Pharmacy

Pharmacy Name:

Pharmacy Address:

Government regulations require we ask for the following identifying information.

Gender:

Race:

Other Race:

Ethnicity:

Primary Preferred Language:

Other Language:

How did you hear about our practice?



Physician Referral
Doctor’s Name:


Friends / Family
Whom may we thank?

Web SearchSocial Media
Other:


Primary care Doctor’s Name:

ALLERGY SYMPTOMS

Please check all that apply

Itchy noseNasal congestionRunny nosePostnasal dripLoss of smellItchy eyesWatery eyesItchy throatEar infectionDizzinessEar poppingEar fullness/pressureSore throatCoughWheezingItchy skin/rashes/hives


During what months are you symptomatic?

Please check all that apply

WINTERSPRINGSUMMERFALLYEAR ROUND

When are your symptoms worse?

Please check all that apply

MorningAfternoonNight

Are your symptoms aggravated by any of the following?

Please check all that apply

IndoorsMowing the lawnAspirinOutdoorsDusty environmentHair Dye/PermDamp areasCar pollutionPerfumesHot weatherAnimals/PetsNewspapersCold weatherCooking odorsWoolDry weatherSmokeCosmetic productsWindy dayPaint FumesCreams/LotionsWeather changeInsecticidesAlcoholic beveragesSeason changeLaundry detergentBeerWineLiquorAir conditioningChemicals (list below)

PREVIOUS ALLERGY EVALUATION

Have you undergone allergy testing before?

YesNo

If yes, please check what type of testing you had ScratchIntradermalRAST
Did you have a positive reaction? YesNo
Please list what you had a positive reaction to below:




Have you received allergy shots before? YesNo
If yes, how long were you treated with allergy shots for?


Have you had an adverse reaction to allergy injections before? YesNo
Have you ever been treated in an emergency room for an allergic reaction? YesNo
If so, please explain:


ASTHMA HISTORY

Are you currently being treated for asthma? YesNo
Have you used your rescue inhaler (Proventil, Proair, Ventolin) more than 2 times a week? YesNo
Have you been awakened because of your asthma symptoms more than 2 times a week?YesNo
Have you been hospitalized in the last year because of your asthma symptoms?YesNo



ENVIRONMENT

Occupation:



At work, are your symptoms

SameWorseBetter

Do you smoke? YesNo
Former Smoker, Quit Date:
If you do currently smoke, how much do you smoke a day?
Are you exposed to second hand smoke? YesNo
Does animal/pet exposure make your symptoms worse?YesNo
Do you have any pets? YesNo
If yes, please list:
Does the pet(s) have full access to the entire house? YesNo
Does the pet(s) sleep in your bedroom? YesNo
If yes, where in your bedroom does the pet(s) sleep?
Pillow

Dacron/PolyesterFeather/DownFoam rubber

Mattress

CottonFeather/DownFoam rubberInnerspringOther

Comforter

ChenilleCottonDacron/PolyesterFeathers/Down

Heating System

CoalElectricGasOilOther

Humidifier

YesNo

Method of Heating

BaseboardFireplaceForced airRadiatorStove

Air Conditioning

Window unitCentral Air

Floor

TileCarpetingArea rugsHardwoodWall to wall carpeting

Furniture

FabricVinylMohairOther

Basement

FinishedUnfinishedDamp