FOR OFFICE USE ONLY PATIENT NO. PLEASE RETURN THIS FORM TO ARKANSAS ALLERGY & ASTHMA CLINIC, P.A. OR BRING IT WITH YOU TO YOUR FIRST APPOINTMENT PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME AGE: Who is your primary care physician? Were you referred by a physician? Yes If yes, by whom: Were you referred by a friend or family member? Yes If yes, by whom: Other physicians you have seen in the past year for this problem: 1. 2. What is the MAJOR PROBLEM that prompted this visit (chief complaint)? I. NASAL/HEAD SYMPTOMS: (If you are having HEAD OR NASAL SYMPTOMS, please fill out Section I. If not, please go to the next section). Itchy eyes Sinus infections Posterior nasal drainage Watery eyes Sore throat Runny nose Sneezing Ear pressure Itching of the throat Itchy nose Headache Stuffy nose Snoring Loss of smell/taste How long have you been having these symptoms? How many years? Months? What is the severity of your symptoms? (Please indicate as mild, moderate, or severe). What are the TRIGGERS that make symptoms worse? (check all that apply) ALLERGENS IRRITANTS WEATHER CHANGES Mowed grass Perfumes Windy days Dead grass Soaps Cold fronts Dead leaves Detergents Temperature Changes Hay Smokes Damp weather House dust Paint Cold Cats Hair spray Heat Dogs Outside dust Time of day Feathers Cosmetics Mold or mildew Tobacco smoke Other: Other animals (Type: ) Eating Lying down Have you had previous allergy testing? Yes Results: Year: M.D.: Have you ever had allergy injections? Yes # of years: Have you ever seen a gastroenterologist? Yes If yes, please give date and information: Date: Name of Dr.: City/State:
IIA. CHEST SYMPTOMS: (If you are having CHEST SYMPTOMS, please fill out Section IIA. If not, please go to the next section). What are you main CHEST symptoms? Cough Shortness of breath Chest infections/bronchitis Asthma/wheeze (go to IIB below) How long has this been a problem? Number of years: Number of months: Age at first episode: Triggers: When sick with colds Worse in the morning Exercise Worse at night Worse with seasons Spring Fall Summer Winter Frequency: Daily > 2 times/week < 2 times/week Continuous # nights per month What is the severity of your symptoms? (Please indicate as mild, moderate, or severe). Do these symptoms influence your level of activity? Yes Have you ever seen a gastroenterologist? Yes If yes, please give date and information: Date: Name of Dr.: City/State: Treatments in the past: Inhalers Steroids Antibiotics Other: IIB. WHEEZING/ASTHMA: (If you are having WHEEZING OR ASTHMA, please fill out Section IIB. If not, please go to the next section). How long has asthma been a problem? Number of years: Number of months: Age at first episode: Triggers: Upper respiratory infections Exercise Nighttime Morning n-seasonal Worse with seasons Spring Fall Summer Winter Pollen exposure Frequency: Daily > 2 times/week < 2 times/week Continuous # nights per month Treatments tried for wheezing: Inhalers (names): Nebulizers (updraft) (names): Steroid shots: # of times # in last year Steroids by mouth: # of times # in last year Emergency room visits needed for asthma/wheezing? Total in life Total in last 12 months Hospitalizations for Asthma: Total in life Total in last 12 months Intensive Care Admissions? Yes # of times Intubation: Yes Was birth premature? Yes weeks early NICU Ventilator x days O2 Had recurrent bronchitis been a problem? Yes # of times Inhalers used? Yes Was the first episode of wheezing associated with RSV or a viral infection? Yes III. SKIN SYMPTOMS: (If you are having SKIN SYMPTOMS, please fill out Section III. If not, please go to the next section). What are your skin symptoms? Hives Eczema Itching Rash Swelling (location: ) How long have symptoms been present? # of years: # of months: # of weeks: Triggers: Medications (name/date started taking): Foods (name foods): Frequency of reactions? All the time daily every few days or weeks What symptoms occur with reactions? Time after ingestion: Treatment: ER visits: Were you given an Epi-Pen? Yes Was an Epi-Pen used for this? Yes
IV. INSECT STINGS: (If you are having GENERAL BODY REACTIONS TO INSECT STINGS, please fill out Section IV. If not, please go to the next section). Suspected insects: Age at first reaction: # of reactions? Symptoms with reaction: Local swelling Shortness of breath Hives (other than at sting site) Wheeze Dizziness Passing out Treatment: ER visits: Were you given an Epi-Pen? Yes Was an Epi-Pen used for this? Yes V. RECURRENT INFECTIONS: (If you are having FREQUENT RESPIRATORY INFECTIONS, please fill out Section V. If not, please go to the next section). Number of bouts of otitis media (ear infections) in life per year PE tubes: Yes # of sets: Number of sinusitis in life per year Number of pneumonias in life per year Number of skin infections in life per year Location(s): Number of recurrent croup episodes in life per year Number of hospitalizations for infections Reason(s): Number of antibiotics in last year Name(s): Have you had a previous immune workup? Yes Date: Have you had a previous ENT consultation? Yes If yes, please give date and information: Date: Name of Dr.: City/State: Have you had a sinus x-ray? Yes Date: Have you had a sinus CT? Yes Date: VI. FOOD REACTIONS: (If you are having REACTIONS TO FOODS, please fill out Section VI. If not, please go to the next section). Suspected food(s): Age when reactions first started: Number of episodes: Dates? Frequency of reactions? Daily Weekly Monthly Only with specific food ingestion Symptoms of the reactions? Treatment: ER visits: Did you have an Epi-Pen on hand? Yes Was the Epi-Pen used for this? Yes VII. PAST MEDICAL HISTORY: GENERAL PERSONAL HEALTH HISTORY: Have you ever had any of the following? (Insert the year) Anemia Yes Cancer Yes If yes, please complete: Type: Year: Treatment: Chemotherapy Radiation Surgery Cataracts Yes Chronic Otitis Media (Ear Infections) Chronic Sinusitis Yes
VII. PAST MEDICAL HISTORY: (continued) Congestive Heart Disease (Heart Failure) Yes Coronary Artery Bypass Graft Yes Coronary Artery Disease Yes Diabetes Yes Eczema/Dermatitis Yes Gallstones Yes GERD (Reflux) Yes Glaucoma (High Eye Pressure) Yes Headaches Yes Heart Disease Yes Hepatitis Yes Hiatal Hernia Yes Hypercholesterolemia (High Cholesterol) Yes Hypertension (High Blood Pressure) Yes Hypoglycemia Yes Irritable Bowel Disease (IRB) Yes Migraine Headaches Yes Mitral Valve Prolapse Yes Pneumonia Yes Psoriasis Yes Rheumatic Heart Disease Yes Seizures Yes Stroke Yes Thyroid Disease Yes Tuberculosis Yes Other illnesses/diagnoses not listed: VIII. MEDICATION ALLERGIES: (Medications I cannot take because of prior reactions or side effects.) NONE ( drug allergies) DRUG/MEDICATION Describe the reaction/allergic symptoms: IX. IMMUNIZATION HISTORY: Are your immunizations up to date? Yes Tetanus booster in last ten years? Yes Have you had a shingles vaccine? Yes Date last received: Pneumonia vaccine Yes Date last received: Influenza vaccine Yes Date last received: Could not receive influenza vaccine because of Egg allergy? Yes
X. FAMILY HISTORY: ALLERGY FAMILY HISTORY: Is there a history of any of the following in your family? Asthma Yes Mother Father Daughter Son Sister Brother Allergic Rhinitis (hay fever) Yes Mother Father Daughter Son Sister Brother Sinus Problems Yes Mother Father Daughter Son Sister Brother Nasal Polyps Yes Mother Father Daughter Son Sister Brother Atopic Dermatitis (eczema) Yes Mother Father Daughter Son Sister Brother Hives Yes Mother Father Daughter Son Sister Brother Food Allergy Yes Mother Father Daughter Son Sister Brother GENERAL FAMILY HISTORY: In your generation, or the generation before you, are there any of the following? Arthritis Yes Rheumatoid Arthritis Yes Cancer Yes Lupus Yes Heart Disease Yes Kidney Disease Yes Hypertension Yes Seizure Disorder Yes Diabetes Mellitus Yes Thyroid Disease Yes Emphysema of the Lung Yes Tuberculosis Yes Migraine Yes Other diseases that are present in your family: SURGERIES: Surgeries Tonsillectomy Yes Date(s): Adenoidectomy Yes Date(s): PE Tubes (ear tubes) Yes Date(s):. of times: Polypectomy (nasal polyp surgery) Yes Date(s):. of times: Septoplasty (nasal bone repair) Yes Date(s): Sinus Surgeries Yes Date(s): Other surgeries: Other surgeries: Other surgeries: Date(s): Date(s): Date(s): HOSPITALIZATIONS: Reason: Reason: Reason: Date(s): Date(s): Date(s):
XI. OCCUPATIONAL/SOCIAL HISTORY: City/state of residence: Most recent occupation: If a student, current grade in school: Workplace exposures: Paper dust Chemicals Other: Types of work done in the past: Any use of marijuana? Yes Alcohol use: ne Occasional Moderate Heavy Do you smoke or use tobacco products? Yes Cigarettes packs/day number of years Pipes Cigars Chewing tobacco Snuff Have you ever smoked tobacco in the past? Yes packs/day number of years year quit XII. ENVIRONMENTAL REVIEW: Tobacco/smoke exposure in home: Yes Current household members: Spouse Children Brothers Sisters Mother Father Total.: Age of home: 0-10 years >10 years How long at present location? 0-5 years 6-10 years >10 years Type of home: Apartment Manufactured / Mobile Home House Heat and air details: Central heat/air Window air conditioners Wood burning stove/fireplace Space heaters Bedding details: Zipper encasings Cotton mattress/pillow Feather pillow Hypoallergenic pillow Feather comforter Feather mattress Pets/animals (inside): Cat Dog Other: Pets Pets/animals (outside): Cat Dog Other: Pets XIII. NUTRITION AND DIET: food intolerances Food intolerances (not listed above): Food: Symptoms produced: Food: Symptoms produced: Amount of milk consumed daily: ne 1 cup or less 2-3 cups 4 or more cups XIV. TRAVEL: Symptoms improve when away from state Travel without symptoms changing
XV. HISTORY AS A NEWBORN: Birth Weight? lb, oz Breast Fed? Yes How long? months Hospital stay after birth? Yes Numerous formula changes in the first 6-9 months of age? Yes Eczema less than three months of age? Yes RSV before three months of age? Yes XVI. MEDICATIONS: (List here or bring a list of current medications or bring all your medications with you): A) List all ALLERGY OR ASTHMA MEDICATIONS taken PRESENTLY including over-the-counter preparations, prescription tablets, oral liquids, inhalers (MDI s), nasal sprays, creams, or eye drops): 1. 2. 3. 4. 5. 6. 7. 8. B) List all ALLERGY OR ASTHMA MEDICATIONS taken in the PAST, including over-the-counter preparations, prescription tablets, oral liquids, inhalers (MDI s), nasal sprays, creams, or eye drops): 1. 5. 2. 6. 3. 7. 4. 8. C) List OTHER MEDICATIONS taken routinely or intermittently for medical reasons (i.e., vitamins, aspirin, blood pressure medications, etc): 1. 5. 2. 6. 3. 7. 4. 8. XVII. SYSTEM REVIEW: Please check those symptoms you have experienced that have been significant or recurring problems in the past 30 days. Comments CONSTITUTIONAL Fatigue Yes Night Sweats Yes Weight Loss Yes Unexplained Fever Yes SKIN Dry Skin Yes Hives Yes Itching Yes Sensitive Skin Yes EYES Itchy Eyes Yes Red Eyes Yes Tearing Yes _
XVII. SYSTEM REVIEW: (continued) RESPIRATORY Shortness of Breath Yes Decreased Exercise Tolerance Yes Sputum Production Yes Wheezing Yes ENT Posterior Nasal Drainage Yes Clear Runny se Yes Sneezing Yes Nasal Congestion Yes Hoarseness Yes Sore Throat Yes Snoring Yes CPAP for Sleep Apnea Yes NECK Neck mass Yes Neck Pain Yes Neck Stiffness Yes Swollen Glands Yes RESPIRATORY Shortness of Breath Yes Decreased Exercise Tolerance Yes Sputum Production Yes Wheezing Yes CARDIOVASCULAR Chest Pain Yes Irregular Heartbeat Yes Elevated Blood Pressure Yes Rapid Heart Rate Yes GASTROINTESTINAL Abdominal Pain Yes Bloody Stool Yes Constipation Yes Diarrhea Yes Difficulty Swallowing Yes Heartburn Yes Indigestion Yes Nausea Yes Vomiting Yes GENITO-URINARY Frequent UTI Yes MUSCULOSKELETAL Joint Pain Joint Redness Joint Swelling Yes Yes _
XVII. SYSTEM REVIEW: (continued) NEUROLOGICAL Fainting Yes Headaches Yes Seizures Yes PSYCHIATRIC Anxiety Yes Depression Yes ENDOCRINE Excessive Thirst Yes Excessive Urination Yes Thyroid Problems Yes HEMATOLOGY Easy Bruising Yes se Bleeds Yes Swollen Glands Yes FOR OFFICE USE ONLY: Physician Signature: Date: