ALLERGY HISTORY QUESTIONNAIRE
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1 Department of Otolaryngology / Head and Neck Surgery Division of Allergy and Environmental Disease ALLERGY HISTORY QUESTIONNAIRE Name: Date: Occupation: Have you ever been tested for allergies? Yes No If yes, please answer the following: By whom? (Include address, if possible) Were you found to be allergic? Yes No To what? Were you treated with allergy shots? Yes No For how long? Did the treatment help? Yes No Section One Symptoms What are the main symptoms that brought you to the doctor? How long have these symptoms lasted? Did anything initiate the symptoms? Does anything make the symptoms better or worse? Are your symptoms worse in: Spring Summer Winter Fall Please check the conditions below which apply to your symptoms: A. Symptoms of Pollen Allergy B. Symptoms of Dust Allergy Worse outdoors Worse indoors Worse on windy days Improved outdoors Worse on sunny days Increased after going to bed or at night Itching eyes Recur or increase each year with the return of cold weather Worse outdoors 7:00 to 11:00 am Nasal symptoms with little or no itching of the eyes Better indoors Worse with air conditioning Improved in air conditioning Increased in dust (such as in dusting or sweeping) Increased on exposure to cold air Page 1
2 C. Symptoms of Mold Allergy D. Symptoms from Specific Contacts Worse outdoors between 4:30 and 8:30 pm Worse in house after lights have been on an hour Increased by cool evening air Worse in certain rooms: Which ones? Worse while mowing or playing on grass Worse in basement Worse from mid-july to November Worse around feed mills or barn Worse at damp or low places React in a home with cats Distinctly aggravated in fall, winter React in a home with dogs Worse in coastal areas Worse in your house, but not in others Worse on rainy days Increased by drinking water Please check any symptoms you are experiencing: A. Respiratory 1. General 2. Nasal Symptoms 3. Cough Pain Runny nose Seasonal Nose bleeds Itching Year-round Loss of weight Congestion Particular time of day Night Sweats Intermittent am Temperature elevation Constant pm Tonsillitis Daytime Worse after colds Frequent colds Nightime Productive Fatigue After meals Color Difficulty sleeping With temperature change Consistency Seasonal: Which ones? Year-round 4. Sneezing 5. Breathing 6. Voice Seasonal Noisy Hoarse Year-round Wheezing Intermittent Upon waking up Daytime only Constant At meals Nighttime only Worse as day progresses After meals Anytime Frequent laryngitis In dust With exercise only In smoke B. Gastrointestinal 1. Mouth 2. Stomach 3. Throat Sore lips Retasting food Sore Sore mouth Nausea Scratchy Sore tongue Vomiting Lump in throat Roof itches Cramps Difficulty swallowing Lip swelling Bloating Page 2
3 4. Rectal 5. Appetite Itching Good Pain Selective Poor C. Cardiovascular 1. Shortness of Breath 2. Swelling 3. High Blood Pressure Daytime Face 4. Chest Pain Nighttime Hands 5. Heart or Pulse Irregular With exercise Legs 6. Previous Heart Disease # of Pillows for sleep? Time of day? D. Neurological 1. Headaches 2. Ears Age at onset Tinnitus or ear ringing Meniere s disease Duration Vertigo or dizziness Hearing fluctuation Frequency Seasonal: Which ones? Seasonal: Which ones? Regular Year-round Year-round Irregular After eating: What foods? After eating: What foods? At menses only With weather change With weather change Migraine On windy days On windy days 3. Fatigue On overcast days On overcast days Upon waking up Frequent infections Hearing loss: Which ears? After meals Fluid behind eardrums Ear fullness or pressure Without exercise Drainage Problems changing altitude Constant E. Musculoskeletal F. Genitourinary G. Skin 1. Aching Muscles 1. Urination 1. Rash 2. Joint Pain Painful Duration Continuous Delayed Location Intermittent Prolonged Generalized (all over) After meals Frequent Localized: Where? Seasonal Daytime 2. Eczema (dry, scaly skin) 3. Arthritis Nighttime 3. Fungal Infection (nails, skin) 4. Bursitis Bed Wetting H. General Pain Nose bleeds Loss of weight Night sweats Temperature elevation Tonsillitis Frequent colds Fatigue Fatigue Difficulty sleeping Watery eyes Itchy eyes Page 3
4 Section Two Environmental Exposures A. Home 1. Type 2. Details 3. Region Single house Slab foundation City, industrial Duplex Crawl Space City, residential Apartement: Floor? Basement Suburban Hotel Papered walls Small town Trailer Sheet rock Rural Garage: Attached? 4. Heating and Ventilation 5. Washer and Dryer 6. Other Central Heat Washer: Location? Indoor plants: Location? Gas Dryer: Location? Types? Electric Gas Fireplace Central Air Electric Wood Gas Feather or down pillows / comforter B. Chemicals in Home Use (Indicate Brand Name) Roach chemical Ant chemical Chlorine cleansers Household cleaners Air fresheners Aerosols Exterminator service Others C. Animals and Birds (Indicate Type) Dog Cat Birds Gerbil, hamster, mouse, etc. Horse Other D. Food Vegetarian Eat organic only On a diet: Type? Food cravings (describe) Food sensitivities or reactions (list food and type of reaction) D. Work Describe your work location: Symptoms worse at work Symptoms improved at work Foul odors or chemicals at work (describe) D. Check Any of the Following That Aggravate Your Symptoms Paint fumes Smoke Cooking odors Newspapers Road dust Air pollution Wool Gasoline Other Page 4
5 Section Three Family History Please indicate if any of your family members have had any of the following health problems: Father Mother Brother Sister Child Hay Fever Asthma Hives Eczema Food Allergies Sinus Problems Thyroid problems Emphysema Diabetes Heart Problems Cancer Section Four General Medical History Please check any of the following medical conditions you are experiencing, or have experienced in the past: High blood pressure Heart disease Heart attack Arthritis Sinus disease Bronchitis Emphysema Asthma Hay Fever Nasal polyps Ulcers Stomach or intestinal disease Thyroid dysfunction Seizures Headaches Migraines Hives Skin disease Food allergies Cancer Fibromyalgia Chronic fatigue Diabetes Please list all current prescription medications and dosages: Please list all current supplements (vitamins, minerals, etc.) and herbs: _ Have you ever had a bad reaction to a medication? Yes No If yes, please list the medication and reaction: _ Do you smoke? Yes No If yes, what do you smoke and how much? Do you drink alcohol? Yes No If yes, what type and how much? Stopped smoking in Stopped drinking in Please check this box if there are any other issues you would like to discuss with the doctor, but do not feel comfortable reporting on this questionnaire. Thank You! Page 5
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