URTICARIA HISTORY General 1. When did your hives (Whelps) begin? 2. Describe the circumstances surrounding your first episode of hives? 3. How often are you having hives now? 4. Are your hives getting worse or occurring more often? 5. When you have hives do you have any of the following symptoms? (Check all that apply) Hives itch flushing of skin chest or throat tightness Hives are painful hoarseness shortness of breath Swelling of other parts of your body (i.e., face, lips, eyes, feet, etc.) 6. What size are the individual hive lesions? 7. When you break out in hives how long do they last? 8. Do your hives consistently occur on your hands, feet or buttocks? 9. Do your hives occur where pressure is constantly applied to your skin, such as under your belt, elastic straps, etc.? 10. What days of the week do your hives usually occur? 11. What days of the week are you usually free of hives? 12. What time of day do your hives usually occur? Location (X) where your hives are WORSE ( ) where your hives are BETTER indoors at home while away on vacation outdoors at work, school the same at all locations N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 1 of 6
List the medications that you have used to control your hives. Please comment on how effective each medication is in controlling your hives. Do you know of anything that causes you to have hives? (Please list) Skin Factors 1. Do you have a tendency for a very Itchy skin? 2. Are you troubled with very dry skins? 3. Have you ever had allergic eczema? 4. Do you have any other chronic recurrent skin rash? Dermographism 1. Do you get Whelp after scratching your skin? 2. Are your hives present before you scratch your skin? 3. Do your hives occur only after you scratch your skin? Cholinergic 1. Do any of these factors cause your hives to start or worsen? heat exercise sweating excitement hot baths exertion emotional upset 2. Do you have any of the following symptoms associated with your hives? headache listlessness abdominal cramps faintness excessive sweating diarrhea Psychogenic 1. Do you relate the onset of your hives to a particular episode of emotional upset? 2. Will becoming angry, excited, or emotionally upset cause your hives to start or worsen? N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 2 of 6
Endocrine 1. Do you have any of the following symptoms? Intolerance to heat change in skin or hair thyroid trouble Women : 2. Are your hives worse before or during your menstrual period? 3. Have your hives ever occurred while you were pregnant? Autoimmune/Serum Sickness 1. Are you having any of the following symptoms? Frequent fever joint stiffness enlarged lymph nodes Loss of weight aching or swelling muscle tenderness Physical Factors 1. Do any of the following factors cause you to have hives or your skin to itch or burn? cold heat water sunlight Miscellaneous 1. Since your hives began have you had any of these symptoms? Purple spots on skin anemia blood, protein or pus in your urine Chronic eczema bleed easily brown spots on skin Atopy 1. Do you have hay fever or asthma? 2. When you have hives do you have any of the following symptoms? Itchy, red eyes sneezing coughing Itching of mouth or nose stuffy, runny nose wheezing 3. Do your hives occur more often during any particular season? Winter Spring Summer Fall 4. Will exposure to any of the following items cause you to have hives? Near trees a lot of house dust playing in grass A damp, musty area playing in weeds birds, feathers Any flowers cats dogs N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 3 of 6
Contactants 1. Does coming into close contact with any of the following items cause you to itch or have hives? Dust Body lotions Paint fumes Smoke Body powders Chemical fumes Silk Toothpaste Fumes from solvents Wool Detergents Odors from foods Cosmetics Fertilizer Any drugs Perfumes Any plants Deodorants To handle any foods 2. Do you know of anything else that you come into close contact with that will cause you to have hives or cause your skin to itch? Foods 1. Do you ever get hives soon after eating a meal? 2. Do any of these symptoms occur after eating a meal or a particular food? Itching of mouth Other skin rash Nausea or vomiting Itching of skin Runny nose Stomach cramps Whelps or hives Wheezing Diarrhea Eczema Stomach bloating Much mucus in stools 3. What foods or beverages caused the symptoms that you checked? 4. Have any of the following items caused you to have hives or itching? eggs cereal tomatoes watermelon seafood citrus fruits pork food coloring Shrimp Peas, beans Spices Bananas Nuts Chocolate Saccharin Beer Milk Cheese Strawberries Wine 5. Do you know of any other foods or beverages that would cause you to have hives? 6. Do you refuse to eat any particular foods? N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 4 of 6
7. Do you eat or drink a large amount of any particular food or beverage? 8. Have you eliminated any foods from your diet? 9. Did this cause your hives to decrease in severity? Infections 1. When you have hives to you usually have fever? 2. Do you have any of the following symptoms? (Check all that apply) Recurrent fever Chronic cough Skin infection Recurrent night sweats Cough up blood Frequent boils Loss of weight Crampy abdominal pain Swollen lymph nodes Frequent headaches Recurrent diarrhea Anemia Bleeding or tender gums Rectal itching Genital itching Pustular nasal discharge Burning on urination Vaginal discharge 3. Have you had any of the following infections? (Check all that apply) Fever blisters Gallbladder infections Pneumonia Frequent tonsillitis Kidney infection Fungus infection Sinus infection Prostate infection Intestinal worms Dental or gum infection Vaginal infection Hepatitis 4. List any other infections that you have had in the past several months. 5. Have you been exposed to anyone with tuberculosis or any other infectious disease? Drugs and Vaccines 1. List the drugs, antibiotics or immunizations that you may be allergic to. Also, describe the reaction that you had to each one (i.e., rash, fever, hives, itching, swollen arm, muscle aches, etc.) N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 5 of 6
2. Are you using occasionally or regularly any of the following medications? Insects Aspirin Pain pills Iron tablets Vitamins Allergy pills Antibiotics Tonics Birth control pills Sulfa drugs Laxatives Tranquilizers Iodine drops Sleeping pills Codeine cough syrup Quinine 3. List any other medicines that you are taking 4. Have you had a penicillin shot within the past three months? 5. Have you ever had x-rays of your kidneys, gall bladder or spine where a dye was injected? 1. Have you ever had hives after an insect bite or sting? 2. If so, what insect caused this? 3. Does coming into contact with moths, caterpillars or other insect debris cause you to have hives? Environmental Survey 1. Check the items that are in your house. Older carpets Overstuffed furniture A basement Older rug pads Feather pillow, etc. A fireplace Fiberglass curtains Cushions with Kapok Dusty closets 2. Is there a room in your house where your hives are worse? 3. Is there mold or mildew growing in your house? 4. Is there anything unusual in your house? (i.e., stuffed real animals, furniture of aromatic woods, items from foreign countries, etc.) 5. What kinds of animals or birds do you have or frequently come into contact with? For more information please visit our website: www.pennstatehershey.org/web/dermatology/home and click on Health Information Library. If you have any questions or concerns, please contact your provider at the location you were treated. Hershey Medical Center, UPC I, Suite 100 (717) 531-6820 or Nyes Road, (717) 657-4045. Penn State Hershey Medical Group, Colonnade Building (814)272-4445. An Equal Opportunity University N:\Shared\Community\Clinic Handouts\Clinic Patient Information (rah) (rev 2/17/11) Page 6 of 6