R. Lawrence Siegel, M.D. Ph.D. ALLERGY PATIENT HISTORY FORM
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1 R. Lawrence Siegel, M.D. Ph.D. ALLERGY PATIENT HISTORY FORM Please answer the following questions with regard to your experiences and do NOT base your answers on previous skin tests (except where asked for). Please print, type, or circle those items which apply, and remember to bring this completed form and any medicines you are taking with you for your appointment. Patient s Name Age Sex Place of birth How long have you lived in this area? Permanent Resident? If not, where is your home? Do you have symptoms at home? I am (better) (worse) in this area. Is your home: urban rural farm. PROBLEMS for which we are seeing you: (Please list in chronological order of onset). PROBLEM: Age of onset Where living at that time Which of the following apply WHEN YOU HAVE SYMPTOMS? (please circle). General: Sinus, frequent colds, fatigue, poor appetite, dizziness, nervousness, weight loss, chills,fever Headache: Where: front, back, top, sides, right, left, behind eyes, above eyes, below eyes. Type: Sharp, dull, aching, throbbing, pressure, better with sleep, wake up from sleep. Associated with: stuffy nose, tension, vomiting, spots before eyes, trouble seeing. Frequency times per Cause: migraine, food, sinus, tension, drugs. Movement causes shifting in head. Skin: Rash, hives, eczema, blisters, itching, swelling, burning, redness, dandruff, athlete s foot. Location on body. Worse (after eating, after drugs, during menses, after exercise, after shower, other ). Eyes: Tearing, itching, burning, pain, redness, discharge (type: watery, thick, yellow), puffiness, blurred vision, sensitivity to light, dark circles under eyes. Ears: Pressure, itchiness, drainage, bleeding, impaired hearing, deafness, recurrent infections, popping, ringing.
2 Nose: Trouble smelling, stuffiness, runny, itching, sneezing, snoring, polyps, post nasal drip, bleeding, trouble breathing, deviated septum, broken nose, sniffling. Mucous is: thick, thin, clear, watery, yellow, green, brown, bloody. Amount per day: teaspoon, tablespoons, 1/2 cup, more 2 Tongue: Swollen, sore, itching, coated, trouble tasting. Mouth: Cough: Chest: Itching of roof, repeated tonsillitis, morning sore throat, bad breath, swollen lip, trouble swallowing, mouth breathing, frequent throat clearing, hoarseness, throat swelling, throat itch, throat tickle, painful teeth. Deep, dry, loose rattle, daytime, nighttime, exertional, constant, emotional, after eating. Phlegm is: thick, thin, clear, watery, yellow green, brown, bloody. Amount of phlegm per day: none, teaspoon, tablespoon, 1/2 cup, more. Shortness of breath, wheeze, pain, tightness, cough, cough then wheeze, trouble breathing on exertion, trouble sleeping, emphysema, bronchitis, TB, recurrent pneumonia, sharp pain with breathing. Stomach: Vomiting, gas, cramps, belching, diarrhea, mucous in stool, blood in stool, worse after eating what foods. Menses: (Females only) Are you pregnant? Yes No. Taking birth control pills? Yes No I.U.D. Yes No. Are you post- menopausal? Yes No. Urine: Pain, burning, frequent, itching, bedwetting, Recurrent infections. Food Allergies: What foods are you allergic to? Insect Venom Allergies: What stinging insects are you allergic to? SYMPTOMS ARE MOST SEVERE Time: Upon arising, Morning, Afternoon, Evening, Night No difference, Any time. Day of the week: Weekdays, Weekends, No difference. Most severe months: Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. All year Locations: Indoors, Outdoors, Work, School, Home (bedroom, den, living room, bathroom, workshop, kitchen garage, anyplace at home), car, boat, library, beauty shop, department stores, no difference.
3 Does travel to other geographical areas make you better or worse (please detail) 3 Most symptom free months: Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. None Are there places where you are free of symptoms? Beach, City, Farm, other HOW OFTEN do you have symptoms? Present, most of the Time, comes and goes. If it comes and goes, how often?. How long does it last on the average? CONDITION is: Getting better, stays the same, getting Worse. Have you been or are you on cortisone type drugs? Yes No. If yes when? For what? Drug or dose Length of time. In the past year, how many days of work/school have you missed because of this problem?. What SPECIFIC THINGS do you know of which cause or worsen symptoms? What type of pillow do you use? Feather Foam Dacron Other How old is it? What type of blanket do you use? What type of mattress do you use? Foam Innerspring Waterbed How old is it? Do you have carpeting? Yes No In the bedroom? Yes No Type What kind of rugpad is under your Carpet?. Is a fabric softener used in the laundry? Yes No Brand? Do you in a: House Apartment Condo Mobile home. How old. If a house, is it: Frame Concrete block Other. What items are in the bedroom? Books, Blinds, Stuffed animals Pets, Carpets, Curtains, Stored clothes, Upholstered Furniture. Is there mold/mildrew growing anywhere in the house? Yes No Where? Animals: Which animals bother you? (Bird, cat, dog, Horse, cattle, gerbil, hamster, rabbit, other ) Do you have any pets? Yes No. What kind? Are they kept in the house? Yes No. Allowed in the bedroom? Yes No. Do you have indoor plants? Yes No Type. What type of heating/air-conditioning? (central, wall Units, fans) Does air conditioning make you: Better No Difference Worse. Does heating make you: Better No difference Worse.
4 4 Please CIRCLE specific items which AFFECT YOU BY CAUSING SYMPTOMS: Irritants: Cleanser, detergent, cooking odor, perfume, Powder, tobacco smoke, other smoke, moth balls, fumes, paint, wax, glue, insect spray, fertilizer, room deodorant, chemical, insect repellants, pollution, dust (sweeping, vacuuming), other. Toiletries: Scented soaps, other soaps, shampoo, shavingcream, after shave, hair spray, spray deodorant, hair tonic, hair dye, hand cream, make-up, tooth paste, denture cream, mouth wash, nail polish, nail polish remover, hand creams, lipstick, mascara, foundations, other Foods: Milk, cheese, all dairy products, seafood, nuts, chocolate, whiskey, wine, beer, juices, corn, pork, egg, spices, tomatoes, strawberries, wheat, citrus, hot drinks, cold drinks, soybean products, other How much milk do you drink in a day? How much alcohol do you drink in a day? Environment: Hot weather, cold weather, humid, dry, smog, fog, pollution, air conditioning, heat being on, rain, change in temperature, wind, change in weather, mold, smell of mildew, bright sunlight, other. Clothing: Wool, Silk, dry cleaned clothes, starched clothes, permanent press, shoes, other Contactants: Poison Ivy or Oak, cut grass, cut flowers, plants, Christmas trees, plastic, fiberglass, rubber, over stuffed furniture, shoe polish, jewelry, newspapers, skin preparations, skin medicines, N.C.R. paper, other Emotions: Does emotional upset, stress, tension, excitement, or nerves cause or aggravate your symptoms? Yes No Drugs: ARE THERE ANY DRUGS TO WHICH YOU ARE ALLERGIC Yes No DRUG REACTION DATE Have you ever had a bad reaction to x-ray dye? Yes No Date. Have you ever had a bad reaction to Penicillian? Yes No Date. Have any medications ever caused wheezing? Yes No Which?. Do you use ASPIRIN or ASPIRIN CONTAINING medicines? Yes No Which ones? How often Do these ever cause you to wheeze, cough, or be short of breath? Yes No. Do sulfites or other preservatives bother you? Yes No Do you use: Laxatives Yes No How Often Brand Sleeping Pills Yes No How Often Brand
5 Do any of the following ever cause you to cough, wheeze, or be short of breath? Exercise, laughing, coughing, hiccupping, foods, eating or drinking, none. Explain: Did you have pneumonia before the age of 2 years? Yes No Have you been hospitalized for pneumonia? Yes No Date Are your symptoms accompanied by fever: Never, occasionally, usually, always. Do you smoke? Yes No What Amount For how long Are you bothered by smoke? Yes No What is your occupation? Any vapors, smells, or chemicals which trouble you? Yes No Explain please What is your spouse s occupation? What are your hobbies? Do they provoke symptoms? Average number of hours of sleep per day: What exercise and how many hours per day: 5 THERAPY What DRUGS have you been on FOR YOUR SYMPTOMS and how Effective were they? Drug Effectiveness Drug Effectiveness Do you use nasal sprays? Yes No Brand(s) How often? For how many years Do you use inhalers for asthma? Yes No Brand(s) How often? How long does one last What are other things have you done to get relief and how effective were they? Have you previously consulted an allergist? Yes No If yes, Name Address Were skin tests done? Yes No. Positive reactions to: Were you placed on injection therapy? Yes No How long? Date of last injection Did injections help? What other advice were you given? PAST HISTORY (Please circle items which apply to you or answer question). As an infant: Cesarean section, normal delivery, birth weight, premature, Rh problems, colic, rash, eczema, bowel obstruction, breast fed, difficulty with first B.M., bottle fed, solid foods started, feeding difficulties, pneumonia, abnormal development, chronic vomiting or diarrhea, bronchiolitis. Have you ever had: food allergies, frequent colds or ear infections, chronic cough, recurrent pneumonia, eczema, bronchitis, sneezing fits, croup, hay fever, asthma, wheezing, hives, chronic vomiting or diarrhea. Any serious illnesses in the past
6 Any medical problems at this time other than allergies 6 Are you taking any medications at this time other than Allergy medicines? Drug Dose For how long Drug Dose For how long Have you ever had any operations? (please give dates) Any other hospitalizations? Any serious injuries? Are you immunizations up to date? Yes No Date of last Tetanus immunization. Date of last tuberculin (T.B.) test. Positive negative FAMILY HISTORY Who in your family has or has had the following (please include maternal and paternal grandparents, parents, brothers, sisters, children, aunts, uncles, and cousins. Hay Fever Sinus Trouble Asthma Bronchitis Sneezing fits Eczema Hives Migraine Emphysema Cystic fibrosis Tuberculosis Sudden swelling Sudden unexplained deaths Number of brothers and sisters Number of children Date of last chest x-ray Date of last sinus x-ray
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