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