Department of Allergy & Immunology
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1 Department of Allergy & Immunology DR. DATE OF APPT. TIME Dear Patient: Please complete the enclosed questionnaire and bring it with you to the Clinic on the day of your appointment. If you have any questions, please feel free to contact us at (813) Thank you
2 ALLERGY, ASTHMA & IMMUNOLOGY Roger V. Fox, M.D. Dennis K. Ledford, M.D Bruce B. Downs Boulevard Tampa, Florida BP Pulse Weight Height (for medical staff completion) MEDICAL HISTORY AND ALLERGY SURVEY Please complete this form. It is important for your doctor to know the details about your medical history and allergy symptoms. You may use the back of each page to complete your answers. NAME AGE DATE Circle the allergy problems that you have: (l) Hay fever/sinus (4) Eczema (7) Drug allergy (2) Asthma/bronchitis (5) Insect allergy (8) Headache (3) Hives (6) Food allergy I. CLINICAL HISTORY A. Describe your major allergy symptoms. How do they make you feel? B. What are your expectations from this allergy consultation? II. SYMPTOMS (check) Eye: Itching Swelling Burning Tearing Discharge Ears: Itching Fullness Popping Decreased Hearing Pain Nose: Sneezing Itching Runny nose Mouth Breathing Nasal obstruction Discolored discharge Snoring Sense of smell impaired Headache Where? How often? How severe? Throat: Itching Soreness Post nasal drip Throat clearing Swelling Chest: Cough Sputum Color and amount Wheezing Chest Tightness Shortness of breath with exercise History of asthma diagnosed by physician Exercise-induced asthma Nighttime wheezing Skin: Dermatitis Eczema Hives Swelling Rashes Where on your body?
3 A. Age of onset of your respiratory allergies (hay fever and asthma) B. Do you have daily symptoms? C. Do you have seasonal symptoms? D. Are you having more allergy problems recently? E. What time of the year are your allergies worse? (Please list months.) F. What time of day or night is the worst time according to you? G. Does any particular exposure (cat, dust, smoke) make you much worse? (Please list.) H. Please list all food allergies. History of milk allergy as an infant? I. Please list all drug allergies. (Please list name of drug, type of reaction, and approximate date of reaction.) J. Have you had a life threatening allergic reaction to a stinging insect (bee, wasp, yellow jacket, hornet, fire ant)? K. Have you had hives previously? L. Have you had eczema (atopic dermatitis as an infant or child) previously? III. PREVIOUS ALLERGY EVALUATION AND TREATMENT A. Name of allergist and city B. Please list your allergies C. Have you received allergy shots? Were allergy shots beneficial? How long were you on allergy shots? D. Is your home environment allergy-free? E. Please list all recent medications prescribed or over-the-counter drugs you have used to treat your allergies. Antihistamines for allergies (Benadryl, Tavist, Trinalin, Seldane, Hismanal, Claritin, Semprex-D, and others): improved not improved sedation Bronchodilators for asthma - theophylline (Theo-Dur, Slo-Bid, Uniphyl) inhaled bronchodilators (Ventolin/Proventil, Maxair, Tornalate, Brethaire, Alupent, Serevent); and oral Ventolin/Proventil: How often do you use? improved not improved adverse reactions Corticosteroids for hay fever or asthma - oral (prednisone); intranasal sprays (Vancenase, Beconase, Nasalide, Dexacort Turbinaire, Rhinocort intrabronchial (Vanceril, Beclovent, Aerobid, Azmacort): How often do you use? improved not improved adverse reactions Last date on prednisone Antibiotics for infections (sinusitis, bronchitis): Name How often do you use? improved not improved adverse reactions (rash) Last date on antibiotics Other treatment (Please list all medications that you take):
4 IV. PAST MEDICAL HISTORY A. Please list all important operations and other significant hospitalizations that you have had, even if they are unrelated to your allergy problem. B. Have you been hospitalized for asthma? When? Have you required emergency room visits or emergency treatment by your physician for asthma? C. Do you have any current medical problems or a history of any medical problems? Diabetes Thyroid disorder High blood pressure Seizures Arthritis Hepatitis Ulcers Other D. Have you ever had a blood transfusion? When? E. Have you experienced recurrent sore throats, repeated sinus infections (how often?) documented by x-ray?, or severe infections (what kind, kidney infection, Meningitis or pneumonia? ), when? F. Have you had nasal polyps, adverse reaction to aspirin, or sinus surgery? G. Do you have any other symptoms or complaints (lack of energy, anxiety, or depression)? H. Please list all your prescribed and over-the-counter medications (include aspirin, laxatives, sleeping medication). I. Have you had a chest x-ray, sinus x-ray, lung function tests, EKG, blood tests? Please comment on the results. J. Are your vaccinations up to date? Tetanus? (every 10 years) K. Do you receive the flu vaccine yearly? L. Have you received the pneumovax (for pneumonia)?
5 V. REVIEW OF SYSTEMS Do you have any of the following? (Check) General weight loss chills fevers loss of appetite dry mouth Eyes and Ears dry eyes change in vision Trouble hearing ringing in ears Skin skin rashes recurrent skin infections Gastrointestinal nausea vomiting diarrhea change in bowel habits trouble swallowing heartburn Cardiovascular chest pain chest pain with exercise calf pain with exercise ankle swelling Kidney trouble starting urine bed wetting burning with urination loss of urine with cough or sneeze frequent urination during the night Blood had anemia bleed or bruise easily swollen lymph nodes Musculoskeletal Morning joint stiffness and aching painful, swollen joints muscle tenderness or pain muscle weakness Endocrine cold intolerance heat intolerance increased thirst frequent urinations Gynecological excess bleeding vaginal discharge change in menstrual cycle Neurological weakness/clumsiness tingling, burning, or numbness of extremities Psychological fearful, anxious excessive worry crying spells trouble sleeping behavior problems Other lumps or bumps under arms, breasts skin rashes in the groin skin rashes between legs skin rashes on the toes skin rashes on the feet VI. ENVIRONMENTAL HISTORY A. Do your symptoms occur around any specific environment, exposure, location, or activity (for example, lawn mowing, animals, dusty environments, old leaves, strong odors, exercise)? B. Do you suspect that anything in your home, work place, or other locations cause your symptoms? C. What type of home do you have and what is the surrounding area like (suburbs; country)? D. Do you have indoor animals or birds? Please list. E. Do you have a feather, foam, or Dacron-pillow? F. Do you have a new or old mattress? Or, a waterbed? G. Do you have wall-to-wall carpeting throughout your home?
6 H. Are your windows opened or closed most of the time? I. Do you have central air conditioning? J. Does air conditioning help your symptoms? K. Do your symptoms become better or worse on vacations, trips, or at the beach? L. Do you have symptoms after eating at home or in a restaurant? M. Does a change in the weather influence your allergic symptoms? M. Do strong odors, powders, fumes, cigarette smoke make you worse? N. How do strenuous activities affect your symptoms? VII. PERSONAL AND SOCIAL HISTORY A. Do you presently smoke (how much and how long)? B. Have you ever smoked and when did you quit? C. How much alcohol do you drink? D. Do you use recreational drugs? (This is confidential.) E. Do you consider yourself at risk for HIV? F. What is your occupation? What are your daily activities? How many days have you missed from work or school? G. Are you exposed to any toxic chemicals, noxious substances, or cigarette smoke? H. How long have you lived in Tampa and/or Florida? I. Where have you lived previously? J. Are you happy with your life? If not, why? K. How many other people live in your home? VIII. Do any of them smoke? FAMILY HISTORY A. Are there any members of the immediate family who have asthma, hay fever, eczema, hives, food allergies, drug allergies, insect allergies, arthritis, recurring and/or frequent infections? Please list and comment. B. Are there any hereditary diseases or other disorders that seem to occur frequently in your family (diabetes, emphysema, heart problems)?
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