ALLERGY & ASTHMA SPECIALISTS OF NORTH FLORIDA, P.A.
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1 ALLERGY & ASTHMA SPECIALISTS OF NORTH FLORIDA, P.A. (904) St. Johns Bluff Rd. S. Suite 202 Jacksonville, FL Kingsley Ave. Suite #401 Orange Park, FL Normandy Blvd. Suite #1 Jacksonville, FL San Jose Blvd. #117 Jacksonville, FL NEW PATIENT QUESTIONAIRRE Date of first visit: - - Patient Name: Last First MI Date of Birth: - - Age: Sex: Male Female Home Phone: ( ) - Cell: ( ) - Work: ( ) - Home Address: address: Emergency Contact Name: Phone: ( ) - Referring Provider: Phone #: ( ) - Address: Primary Provider: Phone #: ( ) - Address: Local Pharmacy: Phone #: ( ) - Address: Mail Order Pharmacy: Phone #: ( ) - Fax #: ( ) - Address: How did you hear about us? Referring Provider Other patient/friend Insurance Website Insurance Book Yellow Pages Health Fair jaxallergy.com Advertisement Internet search (e.g. Google, Yahoo) Other: - Page 1 of 8 -
2 A. What is the ONE main problem (chief complaint) which caused you to visit us? Please explain in your own words. B. What other allergic problems may we address today? Please list. C. NASAL NONE (If none, please check the box and skip to Section D.) 1. Please check if you have any of the following symptoms: Runny Nose Itchy Nose Nose Rubbing Frequent Nose Blowing Sneezing Stuffiness Post-Nasal Drip / Drainage Sniffling Decreased Smell Decreased Taste Snoring Mouth Breathing Frequent Nosebleeds Facial pressure Nasal Polyps Discolored Mucus D. HEADACHE / SINUS NONE (If none, skip to Section E) 1. Where is your pain located? Forehead Temples Mask-Like Behind Eyes Cheeks Back Of Head Right Side Left Side Both Sides 2. What best describes your headache? Sinus Migraine Arthritis Tension Stress 3. Triggers? Bright Lights Loud Noises Nasal Congestion Certain Foods Stress 4. Do you have any other symptoms with the headaches? Nausea Vomiting Vision Changes 5. What makes your headaches better? 6. How many sinus infections have you had in the past 12 months that were treated with antibiotics? E. EYES NONE (If none, please check the box and skip to Section F.) 1. Please check if you have any of the following symptoms: Burning Tearing Itching Redness Eyelid Swelling Dryness F. EARS NONE (If none, please check the box and skip to Section G.) 1. Please check if you have any of the following symptoms: Fullness Popping Pain Plugging Decreased Hearing Dizziness/Light-Headed Ringing Frequent ear infections G. THROAT NONE (If none, please check the box and skip to Section H.) 1. Please check if you have any of the following symptoms: Itching Throat Clearing Hoarseness Frequent Sore Throat Voice Changes Burning Belching Indigestion Heartburn H. COUGH NONE (If none, please check the box and skip to Section I.) 1. Do any of the following make your cough worse? Check all that apply. Post-Nasal Drip/Drainage Exertion/Exercise Laughing Talking on the Phone Lying Down Meals - Page 2 of 8 -
3 I. CHEST/BREATHING PROBLEMS NONE (If none, please check the box and skip to Section J.) 1. Have you ever been diagnosed with and/or treated for asthma? Y N 2. Have you seen a pulmonologist (lung doctor)? Y N If yes, whom do/did you see? 3. When were you first diagnosed with asthma? 4. How have your symptoms changed since that time? Worse Better More Frequent Same 5. Describe a typical episode. Chest Tightness Wheezing Short Of Breath Coughing 6. What makes your asthma symptoms better? 7. Do you use a rescue inhaler (albuterol)? Y N If so, does this relieve your symptoms? Y N 8. In an AVERAGE week within PAST 4 WEEKS, how many times did you use your rescue inhaler? 9. Do you wake up at night with asthma symptoms? Y N If so, how many times in an AVERAGE WEEK? 10. Do your asthma symptoms limit your activity/exercise? Y N 11. Do you feel as if your asthma is under control? Y N 12. Have you ever taken steroid pills (Medrol, prednisone, Orapred) for your asthma? Y N If yes, how many times in the past 12 months? 13. How many times in the past 12 months have you been hospitalized for asthma? Gone to the emergency room or urgent care? 14. Do you have any history of (if applicable)? COPD Emphysema Frequent Pneumonias Fibrosis Scarring Of Lungs Other Lung Disease: J. TRIGGERS *** Please place a check in the appropriate box next to trigger if it flares your symptoms. *** Trigger Nose Eyes Chest Trigger Nose Eyes Chest Trigger Nose Eyes Chest Spring Work Emotions Summer Home Exercise Fall Odors Nasal N/A allergies Winter Smoke Heartburn Season change House dust Foods All year Mold or mildew Alcohol Indoors Pollen Aspirin Outdoors Cats Jacksonville area Daytime Dogs Away from Jacksonville Night Other pets Other: - Page 3 of 8 -
4 K. SKIN RASHES / ITCHING / HIVES / SWELLING / ANAPHYLAXIS NONE (If none, please check the box and skip to Section L.) 1. Please describe your rash/reaction in your own words. 2. Have you seen another physician for your symptoms? No PCP Dermatologist ER Urgent Care Name of physician(s): What diagnosis was made? Date(s) seen: 3. What medications have you taken/were given for your symptoms? Epinephrine (Epi-pen, Auvi-Q) Solumedrol (Steroid Shot) Prednisone Medrol Benadryl Albuterol Inhaler/Nebulizer Hydroxyzine (Atarax/Vistaril) Claritin (loratadine, Alavert) Allegra (fexofenadine) Zyrtec (cetirizine) Clarine Xyzal (levocetirizine) Singulair (montelukast) Doxepin (Sinequan) Zantac (ranitidine)/pepcid (famotidine) Other: 4. What best describes your rash (check all that apply)? Raised Welts Small Bumps Scaly Areas Blisters Lines Of Redness Rough Patches Other: 5. What is the size of the each individual lesion? SMALLER than a pea PEA size NICKEL size QUARTER size HALF DOLLAR size LARGER than half dollar VARYING sizes 6. Where is the rash located (check all that apply)? Scalp Face Neck Chest Back Arms Groin Legs Entire Body 7. When did the rash/reaction begin? Has it changed since then? Same Worse Better 8. How often do you have it? Daily Weekly Monthly Yearly Always Other 9. How long does each individual lesion last? 1-2 Hours 3-23 Hours 1-2 Days Longer Than 2 Days 10. Does the rash do any of the following? Itch Burn Sting Hurt Leave A Bruise 11. Do you have any swelling? Y N If yes, where? Lips Tongue Eyes Hands Feet 12. Have you had any of the following symptoms associated with the rash? Throat Closing Trouble Swallowing Hoarseness Difficulty Breathing Wheezing Nasal Congestion Sneezing Diarrhea Cramping Vomiting 13. Do any of the following produce the hives/swelling/rash? Heat Showering/Bathing Exercise Sunlight Pressure/Prolonged Sitting Vibration Friction/Tight Clothes Rubbing/Scratching Cold Temperatures 14. What do you think caused/triggered your symptoms? 15. Where are your symptoms worse? Home Work Inside Outside Stress Menstrual Periods Pregnancy Other: 16. What makes your symptoms better? 17. Is there any seasonal association to the symptoms? No Spring Summer Fall Winter - Page 4 of 8 -
5 18. Have you noticed an association with any of the following foods with your symptoms? Peanuts Tree Nuts Shellfish Other Fish Milk Eggs Wheat Soy Tomatoes Fruits Preservatives Coloring/Dyes Gum/Candy Meats Other Foods: 19. Have you taken any antibiotics within 4 weeks of the onset of symptoms? Y N If so, which ones? 20. Have you taken any of the following within 4 weeks of the onset of symptoms? Blood Pressure Medications Aspirin Ibuprofen (Advil) Naproxen (Naprosyn, Aleve) Goody s/bc Powders Tylenol Other Pain Meds Cold/Sinus/Flu/Cough Medications Muscle Relaxants Laxatives (Metamucil) Vitamins/Supplements Herbal Meds 21. Have you had any insect bites/stings within 4 weeks of the onset of symptoms? Y N 22. Is there anything that you come in contact seem to trigger your symptoms? No Latex Pets Cosmetics Chemicals/Fumes Soaps Detergents Other: 23. Have you had any of the following within the last 4 weeks? Strep Throat Cold/Viral Infection Flu Skin Infection Yeast Infection Pneumonia Fungal Infection (Nails) Urinary/Bladder Infection Hepatitis Dental Infection/Abcess Diarrhea/Vomiting Other: L. ENVIRONMENTAL 1. How long have you lived in Northeast Florida? 2. Where did you live prior to this? 3. In what part of town do you live? 4. Do you have pets in your home? Y N What kind? 5. Do they spend time: Indoors In Bedroom In Bed Outdoors Only 6. Do you have a gas stove, other gas appliances or gas heat? Y N M. PAST ALLERGIC HISTORY (If possible, please bring allergy testing, injection schedule and records to your visit) 1. Have you ever seen an allergist before? Y N Who? Where? When? 2. Did you have skin testing? Y N If yes, in what year? Blood testing for allergies? Y N 3. Did you ever take allergy shots? Y N If so, when? For how long? Why did you stop? Did you have any reactions to the shots? Y N 5. Have you ever seen an ENT (ears, nose, throat) specialist? Y N Who? When? Why? 6. Have you had sinus surgery? Y N When? Type of surgery? N. DIAGNOSTIC TESTING (If possible, please bring reports of X-rays and CT scans to your visit) 1. Date of last Chest X-Ray/CT Chest? Where? Result? 2. Date of last Sinus X-Ray/CT Sinus? Where? Result? - Page 5 of 8 -
6 O. DRUG ALLERGIES/ REACTIONS (Please use end of questionnaire if you need more room.) NONE Medication Date Type of reaction Medication Date Type of reaction P. FOOD ALLERGIES/REACTIONS (Please use end of questionnaire if you need more room.) NONE Food Date Type of reaction Food Date Type of reaction Q. INSECT REACTIONS (Please use end of questionnaire if you need more room.) NONE Suspected insect Date Type of reaction Suspected insect Date Type of reaction R. CONTACT REACTIONS (e.g. Latex, nickel, etc...) NONE Please describe reactions. T. OTHER EXISTING MEDICAL PROBLEMS U. PREVIOUS ALLERGY/ASTHMA MEDICATIONS : Check if you have ever taken any of the following medications: Antihistamines Benadryl (diphenhydramine) Atarax (hydroxyzine, Vistaril) Chlorpheniramine Claritin (loratadine/alavert) Allegra (fexofenadine) Zyrtec (cetirizine) Xyzal (levocetirizine) Doxepin (Sinequan) Decongestant/Antihistamines/Other Claritin-D Allegra-D Zyrtec-D Clarinex-D Singulair (montelukast) Nasal Sprays Flonase (Fluticasone) Nasonex Nasacort (triamcinolone) Omnaris Veramyst QNasl Zetonna Astelin/Astepro (Azelastine) Patanase Afrin Ipratropium Dymista - Page 6 of 8 -
7 Eye Drops Patanol/Pataday Optivar Lastacaft Elestat Zaditor Bepreve Visine Inhalers Albuterol (Proair, Proventil, Ventolin) Xopenex Maxair Atrovent Combivent Serevent (Salmeterol) Foradil (Formoterol) Symbicort ( 80 / 160 ) Dulera ( 80 / 160 ) Advair HFA ( 45 / 115 / 230 ) Advair Diskus ( 100 / 250 / 500 ) Asmanex Qvar Pulmicort Flovent Alvesco Spiriva Steroids/Miscellaneous Prednisone Medrol Decadron Solumedrol (Shot) Theophylline (Uniphyl, Theo-24) Singulair Xolair Epinephrine (Epi-pen) Over The Counter Allergy Medications/Nasal Spray/Eye Drops: CURRENT MEDICATIONS (include all medications that you are taking) NONE NONE Name and dose Times per day How long have you taken? HERBAL MEDICATIONS/SUPPLEMENTS/VITAMINS : V. IMMUNIZATIONS 1. Do you receive a yearly flu shot? Y N Year of last shot? 2. Have you ever received a pneumonia shot? Y N Year of last shot? 3. Have you had the pertussis shot after age 18? Y N Year of last shot? 4. Have you ever had the shingles shot? Y N Year of last shot? - Page 7 of 8 - NONE
8 W. FAMILY HISTORY 1. Does anyone in your immediate family have any of the following medical conditions? Nasal allergies Food allergies Insect allergies Drug allergies Immune deficiency Swelling Asthma COPD/emphysema X. DRUG HISTORY 1. Do you smoke? Y N If so, packs/day for years. 2. Have you ever smoked? Y N If so, packs/day for years. In what year did you quit? 3. Do you live with anyone who smokes? Y N 4. Do you drink ALCOHOL currently? Y N If so, how much? 6. Do you use ILLICIT DRUGS or NARCOTICS? Y N 7. What is your occupation? If none, are you: Retired Disabled Z. REVIEW OF SYSTEMS: GENERAL Excessive fatigue Weight loss. How much? Weight gain. How much? Fever (within the last week) Chills Loss of appetite Symptoms affect work performance Symptoms cause difficulty sleeping Symptoms limit quality of life Co-workers/students comment on allergy/asthma symptoms SKIN Recurrent rash Persistent itching Excessive dryness EYES Excessive tearing Cataracts/Glaucoma HEART Difficulty with exertion Palpitations GASTROINTESTINAL GERD/Acid Reflux/Heartburn Nausea Vomiting Diarrhea Abdominal pain Problems swallowing GENITOURINARY Difficulty urinating Blood/protein/sugar in urine Recurrent urinary infections Prostate problems (men) HEME/LYMPH Anemia Blood transfusion (ever) Easy bleeding/bruising Swollen glands Tender glands ENDOCRINE Overweight Thyroid problems Cold intolerance Heat intolerance MUSCULOSKELETAL Joint pain Joint swelling Osteoporosis/osteopenia Low Vitamin D level NERVOUS SYSTEM Seizures Stroke or TIA Vertigo Dizziness Head injury Tremors Restless legs PSYCHIATRIC Depression Frequent anxiety/tension Difficulty concentrating Thank you for choosing us as your allergy and asthma specialists! Do you have any additional information/comments to add or clarify: - Page 8 of 8 -
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1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
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