ALLERGY QUESTIONNAIRE
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1 ALLERGY QUESTIONNAIRE CLIENT INFORMATION Today s Date: Date of Birth Name: Address City State Zip Home Phone: Work Phone Cell /Pager: Age Male Female address Marital Status: Married Single Divorced Separated Other Mother s Name if minor Father s Name if minor Name of Individual to contact in case of emergency: Phone : Number of Children: Names and ages of children: Your Occupation: Your Employer Employer s Address Employer s Number _( ) Referred to this office by: TV Screening Where? AT&T Yellow Pages Health beat WECT WWAY Clinic Location Newspaper Letter Health Journal Post Card Radio Flyer Attorney Phone Call Friend Name? MD Name? Other Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand: An Allergy is NOT a disease. It is nothing more than your body reacting inappropriately to what should be a harmless substance, consequently activating the body s natural defense mechanism in the form of symptoms. A symptom is an attempt by your body to tell you that something is wrong. We will be addressing the cause of your allergy. We do not use medications in this program. Our procedures are safe, painless and effective for people of all ages. ARE YOU ALLERGIC TO ANY MEDICATIONS? NO YES WHAT KIND? ARE YOU TAKING ANY MEDICATIONS? NO YES WHAT KIND? ARE YOU PREGNANT? NO YES THESE PROBLEMS ARE: RAPIDLY IMPROVING SLOWLY IMPROVING GRADUALLY WORSENING FLUCTUATES BUT GETTING BETTER REMAINS THE SAME RAPIDLY WORSENING SYMPTOMS ARE WORSE IN THE Morning Afternoon Evening SYMPTOMS/COMPLAINTS: COME & GO ARE CONSTANT AGE WHEN SYMPTOMS STARTED Infant (Age 0-3) Adolescent (Age 13-18) Adult (Age 26-40) Child (Age 4-12) Adult (Age 19-25) Adult (Age 41+) NAME AND LOCATION OF DOCTORS PREVIOUSLY SEEN FOR PRESENT CONDITION(S): Please List Possible Foods that Cause Symptoms Please List Drugs that Cause Symptoms. Please List What Animals Cause Symptoms.
2 PLEASE CHECK WHICH ALLERGIC SYMPTOMS APPLY: SYMPTOMS ARE WORSE: Outdoors, and better indoors At nighttime In the bedroom or when in bed During windy weather During wet or damp weather When the weather changes During known pollen seasons In certain rooms or buildings When exposed to tobacco smoke Yard Work, cut grass, leaves, or hay Sweeping or dusting In Air conditioned rooms Don t Know SYMPTOMS ARE BETTER: After shower or bath In air conditioned room Indoors During or after physical activity After taking medication With allergy shot Don t Know NASAL SYMPTOMS: Sneezing Runny Nose Clear discharge Runny Nose Cloudy discharge Worse during pollen season Worse with animal exposure Post nasal drip EAR SYMPTOMS: Hearing Loss Blocking, Fullness, Popping Frequent Ear Infections Ear Tubes Inserted Ringing in Ears FREQUENCY & SEVERITY OF SYMPTOMS: Constant, chronic with little change Present Most of the time Present part of the time Present rarely No interference with normal life Slight interference with normal life Considerable interference with normal life Prevents most normal activities EYE SYMPTOMS: Excessive watering Redness Swelling Worse during pollen season Worse with animal exposure Worse with smoke or chemical exposure SKIN SYMPTOMS: Hives Rashes Eczema Swelling Sores Once had rashes in the bends of knees & elbows Worse during pollen season Worse with animal exposure Skin symptoms are rare Skin symptoms are chronic THROAT & MOUTH SYMPTOMS: of the Throat and Mouth Frequent Sore Throats Frequent Laryngitis Frequent Tonsillitis Mouth Sores Swelling of the Tongue or Mouth
3 CHEST SYMPTOMS: Tightness Asthma or Wheezing with Exercise Asthma or Wheezing around Animals Asthma or Wheezing during Pollen Season Asthma or Wheezing around Smoke Shortness of Breath Dry Coughing BONE & JOINT SYMPTOMS: Bone & Joint Pain Redness or Swelling of Joints Joint Stiffness, Limited Motion Muscle Pain Muscle Weakness Wet Coughing Emphysema Frequent Bronchitis Recurring Pneumonia Chest Pain COPD CHRONIC GASTROINTESTINAL SYMPTOMS Nausea & Vomiting Diarrhea Gas, Heartburn Cramps or Bloating Abdominal Pain Other Symptoms Which Symptoms are the most bothersome? PLEASE EXPLAIN WHAT YOU HAVE DONE TO TRY TO FIX THE PROBLEMS. HAVE ALL OF THESE TREATMENTS FAILED TO FIX YOUR PROBLEM? YES NO HOW HAS THIS PROBLEM AFFECTED YOUR DAILY ACTIVITIES? PLEASE CICLE YOUR LEVEL OF DISCOMFORT ON THE SCALE BELOW. NO DISCOMFORT WORST Briefly describe the reason for your visit and what you hope to accomplish: What type of care are you looking for? Temporary Relief Maximum Recovery
4 PATIENT HISTORY REVIEW OF SYSTEMS 0 = NEVER HAD 1 = PATIENT PRESENTLY HAS 2 = PREVIOUSLY HAD GENERAL MUSCULOSKELETAL NEUROLOGICAL Recent weight gain Arthritis Lightheaded/Dizzy Recent weight loss Rheumatoid Arthritis Memory loss Fatigue Broken Bones Headaches Fever Osteoporosis Migraines Allergies Gout Numbness Loss of appetite Scoliosis Weakness Chills Spinal Trauma Stroke Cancer of Any Kind Joint Pain (anywhere) Tingling/Numbness CARDIOVASCULAR RESPIRATORY INTERGUMENTARY (SKIN) Heart Attack Coughing Bruise Easily Swelling of Ankles Coughing Up Blood Skin Rashes High Blood Pressure Chronic Cough Discoloration Low Blood Pressure Chest Pain Psoriasis Shortness of Breath Asthma Changes in Moles Pain Down Left Arm Pneumonia Sores Profuse Sweating Bronchitis Scars High Cholesterol Tuberculosis EYES, EARS, NOSE & THROAT GASTROINTESTINAL GENITOURINARY Blurred Vision Gall Bladder Problems Painful Urination Double Vision Liver Problems Blood in Urine Ear pain Pain over Stomach Frequent Urination Hoarseness Ulcers Kidney Infection Nose Bleeds Colitis Kidney Stones Glaucoma Hiatal Hernia Incontinence Dental problems Blood in Stool Other/Explanations: Physician/Staff Signature
5 Informed Consent For Anaphylaxis Laser Allergy Relief Centers Anaphylaxis: Anaphylaxis is a severe life threatening allergic reaction to food, insect bites, medication or latex. It can also be exercise induced. Anaphylaxis can lead to death. Symptoms may include but are not limited to: Face - Itchy eyes or nose, flushed face, swelling of tongue and lips, metallic taste Skin - Itchiness, redness, hives, swelling of skin anywhere on the body Throat - Itchiness, tightness, hoarseness, hacking cough, difficulty swallowing, choking Lungs - Difficulty breathing, shortness of breath, repetitive coughing, wheezing Stomach - Vomiting, nausea, stomach pain, diarrhea General - Dizziness, unsteadiness, drowsiness, sense of impending doom, loss of consciousness Initials: I understand that Laser Allergy Relief Centers does not treat nor claim to treat anaphylaxis or allergies that can cause anaphylaxis and I will not hold them responsible for any anaphylactic reaction that may occur due to an allergic reaction that causes anaphylaxis. I understand that anaphylaxis can be a life threatening reaction and I understand the symptoms of an anaphylactic reaction and will in no way hold Laser Allergy Relief Centers responsible for a future anaphylactic reaction. If an Epipen has been prescribed, I agree to carry an Epipen with me at all times and will use it according to the manufacture s recommendations If I have allergic reactions that resemble anaphylaxis. I agree to keep my prescription up to date for my Epipen. I agree that if I have any of the previous symptoms of anaphylaxis described above that I will follow the following procedures. 1) Administer epinephrine (adrenaline) injection immediately. Give a second dose in minutes if reaction continues or worsens. 2) Call 911 and tell them someone is having a life-threatening allergic reaction 3) Go to the hospital immediately even if symptoms subside. Remain for observation 4-6 hours I agree to stay away from drugs, insects and chemicals that I know I am allergic to especially if they have caused anaphylactic episodes in the past. Even after Laser Allergy treatments are complete I agree to always inform doctors and hospitals if I am allergic to any drugs or foods. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE I have read or have had read to me the above explanation Laser Allergy Relief and the related treatment. I have discussed it with the doctor and have had my questions answered to m satisfaction By signing below I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I herby give my consent to treatment. Patient Printed Name Date Patient Signature Dr. Signature The patient had the following questions and was supplied the following answers: It is my clinical opinion this patient is oriented to time and space: YES NO It is my clinical opinion this patient understands the language involved: YES NO
6 Informed Consent to Assessments and Cold Laser Therapy I hereby request and consent to the performance of assessments, various modes of bodywork, laser therapy, and other procedures, on me by the practitioners listed at this clinic and or anyone working at this clinic authorized by the practitioners. I have had the opportunity to discuss the nature and purpose of assessments, various modes of physical therapy, laser therapy and other procedures. I understand that results are not guaranteed. I understand that cold laser therapy is a medical treatment that uses specific wavelengths of light to impart energy into injured cells and tissues. This energy is transformed from photon energy to biochemical energy in the cells which can then be used for balancing the energetic body. The expected direct outcomes from laser treatment may include reduced inflammation, detoxification and reduced allergen/stressor response. The indirect outcomes may include increased energy, comfort and activity levels. Alternatives to cold laser therapy include, but are not limited to traditional allergy treatments, anti-inflammatory or anti-pain medication, medical, chiropractic or naturopathic treatment. I further understand and am informed that, as in all health care, in the practice of cold laser therapy there are some risks, including but not limited to short term aggravation of symptoms and skin irritation. When used in combination with certain medications laser therapy can cause rashes or burns and I therefore understand that I must disclose all information on my current medications to the practitioners at this clinic. Treatment over active cancer may increase the rate of tumor growth; I understand that I must disclose any history of cancer. I also understand that the laser can cause damage to the eyes when viewed directly and that laser safety eyewear, supplied by this clinic, must be worn by me during laser treatments. I do not expect the practitioners listed at this clinic to be able to indicate or explain all risks and complications and I wish to rely on the exercise of judgment during the course of assessment and/or procedures which the practitioners feel at the time, based upon the facts known, is in my best interest. I consent to the assessments, various modes of therapy, including but not limited to laser therapy, offered or recommended to me by the practitioners in this clinic. I intend this consent to apply to all my present and future care in this clinic. Dated this day of, 20. Patient/Guardian Signature: Name of Patient: Signature of Witness: Name of Witness:
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