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716.832.8500
office@paulyoungmd.com

Conditions We Treat
For Patients
About
- Dr. Paul Young, MD
- Meet the Team
Contact
Blog
Pay Bill

Conditions We Treat
For Patients
About
- Dr. Paul Young, MD
- Meet the Team
Contact
Blog
Pay Bill

ALLERGY HISTORY QUESTIONNAIRE

Today’s Date YYYY-MM-DD format

General Information

First Name

MI

Last Name

Social Security Number:

Date of Birth: YYYY-MM-DD format

Address 1:

Address 2:

City

State

Zipcode

Phone Numbers

Home

Cell

Work

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

Home Cell Work

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

Yes No

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

Yes No

If so, whom?

E-mail Address

E-mail address (Required Field)

Work

Occupation

Employer

Preferred Pharmacy

Pharmacy Name

Pharmacy Address

Government regulations

Require we ask for the following identifying information.

Gender

Female Male

Race

Caucasian African American American Indian/Alaska Native Asian

Other Race

Ethnicity

Non-Hispanic Hispanic

Primary Preferred Language

English Spanish

Other Language

How did you hear about our practice?

Physician Referral

Doctor’s Name:

Friends / Family

Whom may we thank?

Web Search Social Media Other:

Primary care Doctor’s Name:

ALLERGY SYMPTOMS

Please check all that apply

Itchy nose Nasal congestion Runny nose Postnasal drip Loss of smell Itchy eyes Watery eyes Itchy throat Ear infection Dizziness Ear popping Ear fullness/pressure Sore throat Cough Wheezing Itchy skin/rashes/hives

During what months are you symptomatic?

Please check all that apply

Winter Spring Summer Fall Year Round

When are your symptoms worse?

Please check all that apply

Morning Afternoon Night

Does any of the following aggravate your symptoms?

Please check all that apply

Indoors Mowing the Lawn Aspirin Outdoors Dusty Environment Hair Dye/Perm Damp Areas Car Pollution Perfumes Hot Weather Animals/Pets Newspapers Cold Weather Cooking Odors Wool Dry Weather Smoke Cosmetic Products Windy Day Paint Fumes Creams/Lotions Weather Change Insecticides Alcoholic Beverages Season Change Laundry Detergent Beer Wine Liquor Air Conditioning Chemicals (List Below)

PREVIOUS ALLERGY EVALUATION

Have you undergone allergy testing before?

Yes No

If yes, please check what type of testing you had Scratch

Scratch Intradermal RAST

Did you have a positive reaction

Yes No

Have you received allergy shots before?

Yes No

Have you had an adverse reaction to allergy injections before?

Yes No

Have you ever been treated in an emergency room for an allergic reaction?

Yes No

ASTHMA HISTORY

Are you currently being treated for asthma?

Yes No

Have you used your rescue inhaler (Proventil, Proair, Ventolin) more than 2 times a week?

Yes No

Have you been awakened because of your asthma symptoms more than 2 times a week?

Yes No

Have you been hospitalized in the last year because of your asthma symptoms?

Yes No

Environment

At work, are your symptoms

Same Worse Better

Do you smoke?

Yes No

Former Smoker, Quit Date:

Are you exposed to second hand smoke?

Yes No

Does animal/pet exposure make your symptoms worse?

Yes No

Do you have any pets?

Yes No

Does the pet(s) have full access to the entire house?

Yes No

Does the pet(s) sleep in your bedroom?

Yes No

Pillow

Dacron/Polyester Feather/Down Foam rubber

Mattress

Cotton Feather/Down Foam rubber Innerspring Other

Comforter

Chenille Cotton Dacron/Polyester Feathers/Down

Heating System

Coal Electric Gas Oil Other

Humidifier

Yes No

Method of Heating

Baseboard Fireplace Forced air Radiator Stove

Air Conditioning

Window unit Central Air

Floor

Tile Carpeting Area rugs Hardwood Wall to wall carpeting

Furniture

Fabric Vinyl Mohair Other

Basement

Finished Unfinished Damp

Quick Links

Allergy Clinic

Ear & Hearing

Sinus & Nasal

Throat

About Us

Contact

Contact Us

Address: 4955 Bailey Ave. Suite #202, Amherst, NY 14226.
716.832.8500
716.832.8501