Patient Questionnaire
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- Erin Allison
- 5 years ago
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1 Patient Questionnaire Patient Name: Patient SSN: - - (First) (Middle) (Last) DOB: AGE: SEX: Parent/Guardian (if applicable) Parent/Guardian SSN: - - Address: Home Phone ( ) City: State: Zip Code: Other (Cell, Work) ( ) Do you have any family members who have ever been patients here? Y N If YES, who: Have you ever had allergy skin testing or received allergy injections in the past? Y N Were you referred by a physician? Y N If YES: Do you have a PRIMARY CARE PHYSICIAN? Y N If YES: NAME: ADDRESS: PHONE NUMBER: NAME: ADDRESS: PHONE NUMBER: Please list all CURRENT MEDICATIONS, including non-prescription, vitamins, herbal, etc. MEDICATION STRENGTH DOSAGE MEDICATION STRENGTH DOSAGE Please list all MEDICINE ALLERGIES or INTOLERANCES. MEDICATION REACTION/SYMPTOMS PHARMACY NAME: Phone # Are your immunizations up to date? Please give a brief description of the PRINCIPLE REASON you are here: Signature of patient/responsible individual: Date:
2 CHECK THOSE BOXES WHICH RELATE TO YOUR SYMPTOMS: Nasal Symptoms: Sneezing Nasal discharge Watery Mucus Yellow Blood-tinged Nasal stuffiness Relieved by medication Varies with change in environment Changes with seasons Dryness Nose bleeds Snoring Mouth breathing Sinus Symptoms: Sinus pressure Sinus pain Headaches Sharp/stabbing Throbs/pounds Dull/aching Lasts 1-3 days More than a week Present on awakening Recurs at same time Particular seasons Worse with weather changes Preceded by aura Eye Symptoms: Itch Water Swollen Dry Scratchy Ear Symptoms: Popping Pressure Earache Fullness Ringing Recurrent childhood infections Recent ear infections Throat Symptoms: Sore throat Hoarseness Lump in throat Tightness Throat clearing Phlegm in throat Asthma/Lung Symptoms Wheezing Shortness of Breath Awakens at night Cough Dry Continuous During day During night Coughing up sputum Wheezy cough Hacking cough Loose cough Non-productive Chest tightness Difficulty breathing Chronic Acute New onset Laying down Sitting up Worse at night Environmental exposures Skin Symptoms: Generalized Localized Scalp Palms and soles Dry Skin Chronic Generalized Localized Hands Face Creases Feet Cracking Rash Redness Stinging Insects: Allergy to: Bee Wasp Hornet Yellow jacket Ants Other Food Allergy Allergic reaction from ingested food Allergy to: Milk Wheat Seafood Fish Shellfish Soy Peanuts Nuts Eggs Chocolate Other Food Intolerance: Fatty foods Milk Miscellaneous: Complaint of Allergic Reaction from contact seasonal from inhalation Complaint of recurrent infection
3 CHECK THOSE BOXES WHICH RELATE TO YOUR SITUATION: PAST MEDICAL HISTORY: Surgeries/Hospitalizations Previous Emergency Room Visits for asthma Previous Emergency Room Visits for Allergic reactions Previous Emergency Room Visits other No prior serious illnesses SOCIAL HISTORY: Activities/Hobbies: Sports Recreational Outdoors Gardening/yard work Painting/woodworking Arts and crafts Work Environment: Homemaker/Home Office Office worker Outdoor worker Smoking History Never Smoked Quit How long ago? Smoke cigarettes For how long? How many per day? Cigars day Pipe Second-hand smoke in home Alcohol History: Do not drink Social Drinker Moderate Drinker ENVIRONMENT HISTORY: Home: City/Country Private Residence Apartment Pets: Indoors Dogs Cats Other: Flooring: Carpet Hardwood Tile Bedroom: Feather pillow Synthetic pillow Standard mattress Waterbed mattress Tempurpedic mattress Uses mattress encasements Uses pillow encasements No encasements Heating/Air conditioning: Central heat Space heaters Fireplace No heating Central air conditioning No air conditioning
4 CHECK THOSE BOXES WHICH RELATE TO YOUR SITUATION: FAMILY HISTORY: Mother s History Father s History Brother/Sister History REVIEW OF SYSTEMS: General Health Feeling fine Fever Chills Night Sweats Recent change in weight Lethargy Heart: Chest pain Palpitations Murmur Ankle swelling Ear, Nose & Throat: Loss of hearing Ringing in ears Crooked nose Mouth sores Gastrointestinal: Nausea Vomiting Heartburn Difficulty swallowing Abdominal pain Constipation Diarrhea Change in stools Genitourinary: Urinary infections Loss of urinary control Urinary stones Painful urination Blood in urine Bone & Joint: Joint pains Joint swelling Joint stiffness Muscle weakness Back pain Skin: Lesions Dry skin Sensitivity to sunlight Neurologic: Fainting Dizziness Headaches Decreased concentration Convulsions Endocrine: Excessive thirst Temperature intolerance Excessive eating Frequent weight changes Psychiatric: Mood changes Energy level changes Behavior changes Sleep disturbances
5 How to Prepare for Being Skin Tested Please follow these directions when getting ready for this test. All antihistamines may affect the results of skin testing and therefore need to be stopped before the testing is done. If the antihistamines are not stopped, testing may be delayed resulting in the need for another clinic visit for skin testing. Please stop these antihistamines for the length of time listed before your appointment at the Oklahoma Allergy & Asthma Clinic. Stop these antihistamines for 5 days before your appointment: Allegra (Fexofenadine) Atarax, Vistaril (Hydroxyzine) Zyrtec (Cetirizine) XyZal (Levocetirizine) Stop these antihistamines 3 days before your appointment: Actifed, Dimetapp (Brompheniramine) Astelin, (Azelastine) Astepro (Azelastine) Benadryl (Diphenhydramine) Chlortrimeton (Chlorpheniramine) Claritin (Loratadine) Clarinex (Desloratadine) Patanase (Olopatadine) Phenergan (Promethazine) Rescon (Chlorpheniramine/methscopolamine/phenylephrine) Respa (Guaifenesin/phenylephrine) Rynatan (Chlorpheniramine, Phenylephrine) Tavist, Antihist (Clemastine) Actifed, Aller-Chlor, Bromfed, Drixoral, Dura-tab, Novafed-A, Ornade, Poly-Histine-D, Trinalin (Combination Medicines) If you are taking an antihistamine that is not listed please stop the medicine for 3 days before your appointment. If you are not sure if the medicine you are taking is an antihistamine, ask your doctor. Sometimes antidepressants can also act as an antihistamine. Let your doctor know if you are on any antidepressants before your skin testing. DO NOT TAKE YOUR ASTHMA MEDICATIONS THE MORNING OF YOUR APPOINTMENT SO THAT A MORE ACCURATE PULMONARY FUNCTION TEST CAN BE DONE. IF YOU ARE BEING SEEN FOR CHRONIC HIVES, YOU DO NOT HAVE TO STOP TAKING YOUR ANTIHISTAMINES. CONTINUE TO TAKE ALL YOUR OTHER NON-ALLERGY MEDICINE FROM YOUR OTHER PHYSICIANS, ACCORDING TO YOUR REGULAR, DAILY SCHEDULE.
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New Patient Information
New Patient Information Thank you for choosing Central Indiana Allergy. In order to provide the most thorough evaluation of your problems, we ask for your assistance with the following items: Complete