ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR

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Transcription:

ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR Name D.O.B. Date Reason for your visit today: Please put a check and complete the blanks which apply to your symptoms: Present Problem Past Problem Not a Problem Eye symptoms: (wear contacts? ) Y/N c c c Watering c c c Redness c c c Swelling c c c Burning c c c Dryness c c c Foreign Body Sensation c c c Symptoms in the upper respiratory tract (nose, sinuses, throat, Eustachian tubes, voice box): Sneezing c c c Congestion c c c Headache c c c Obstruction c c c Drainage c c c Soreness c c c Dryness c c c Hoarseness c c c Hearing Loss c c c Polyps c c c Snoring c c c Impaired Smell/Taste c c c Symptoms in the lower respiratory tract (windpipe, bronchi, lungs) Coughing c c c Wheezing c c c Tightness-Congestion c c c Shortness of Breath c c c Sputum production c c c

Symptoms in the stomach and digestive system which you suspect might be allergic: Present Problem Past Problem Not a Problem Pain/difficulty swallowing c c c Nausea or vomiting c c c Heartburn/indigestion c c c Abdominal cramping c c c Constipation/Diarrhea c c c Hives/Giant Swelling? c c c Eczema? c c c Skin reaction to poison ivy/oak, metals, chemicals or cosmetics? c c c Reaction to food (s) c c c List foods Reaction to bee, hornet, wasp, yellow jacket or other stinging insect bite c c c Reaction to immunization c c c Latex reactions (gloves, balloons, etc) c c c Problems with Immune System c c c Frequent/serious infections c c c Review of Systems (Please indicate if you are currently experiencing any of the following): General: Cardiovascular: c Fatigue c Chest pain c Anemia c Palpitation c Fainting c Edema (swelling) of the legs c Night sweats c Night coughs c Low-grade fever c Irregular heartbeats c Dizziness c Other: c Other: HEENT: G.I.: c Frequent colds c Heartburn c Hoarseness c Nausea c Tonsillitis c Vomiting c Swollen glands c Abdominal pain c Blurred vision c Diarrhea c Ear infection c Nosebleeds c Other:

Respiratory: Musculoskeletal: c Shortness of breath c Arthritis c Difficulty breathing c Joint swelling c Chest tightness c Back pain c Coughing c Stiffness c Wheezing c Coughing blood c Other: Skin: c Easy bruising c Hives c Skin infections c Eczema c Other: Medication Allergies & Intolerances: c NO KNOWN MEDICATION ALLERGIES OR INTOLERANCES PLEASE LIST ANY MEDICATION ALLERGIES OR INTOLERANCES: MEDICATION NAME DATE OF REACTION TYPE OF REACTION (Attach extra information if more than 5 medication reactions) FAMILY A/I HISTORY Father Mother Sibling Paternal Maternal Grandmother Grandmot /father her/father Asthma c c c c c c None Rhinitis/Hayfever c c c c c c Dermatitis (Eczema) c c c c c c Autoimmune disease c c c c c c

Environmental History: Residence Location: Suburban Urban Rural Type of Residence: House Apartment Other Basement: No: Yes( Damp Dry) Air Conditioner: Central Window/Wall Units None Dehumidifier Humidifier Heating System: Forced Air Radiator/Basebord Space heater Fireplace/Wood Stove/Furnace filter changed every months Type of Floors: Living area Carpet Wood Vinyl Other ( ) Bedroom: Carpet Wood Vinyl Other ( ) Type of Bed: Waterbed Conventional Mattres Boxspring ( Allergy encasement) Type of Pillow: Feather Polyester/Dacron Foam ( Allergy encasement) Pets: NO PETS Dog: Outdoor Indoor Bedroom Cat: Bird: Outdoor Indoor Bedroom Outdoor Indoor Bedroom Other: Outdoor Indoor Bedroom *Smokers in Residence: None Yes ( ) Occupational History: Current Occupation Any current exposure to occupational antigens/irritants (dust, mold, pets, grass, pollen, paint, fumes, chemicals, VOCs, pollutants, smoke)? Yes No (If yes, details ). Any previous exposure to occupational antigens/irritants? Yes No (If yes, details Immunization Status (Vaccines): Date of Last Influenza (Flu) Vaccine? (if known) Date of Last Pneumovax or Prevnar (Pneumococcal pneumonia) vaccine? (if known) Signature: Date:

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