Allergy History

Please correct the errors described below.

Name

Date

WHICH SYMPTOMS HAVE YOU EXPERIENCED?

Hay Fever

Cough

Headache

Colitis

Runny Nose

Cough at Night

Diarrhea

Mental Dullness

Stuffy Nose

Wheezing

Constipation

Nausea

Sinus Problems

Shortness of Breath .

Stomach Problems

Fatigue .

Itching Eyes

Tight Chest ,

Hives

Sleep Problems

Post Nasal Drip

Exercise Problems

Severe Acne

Mood Changes

Sneezing .

Arthritis

Eczema

Rashes

Asthma

Known Allergies

How long have you had these symptoms

0 -1 yrs 1-5 yrs 5-10 yrs 10+ yrs

What time of year do you have these symptoms?

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec All Year

What do you think you are allergic to?

Are your allergies worse when you are outside?

Yes No

Have you been evaluated for allergies before?

Yes No

When?

Where?

Do you receive allergy shots?

Yes No

ls there a family history of allergies or asthma?

Mother

Father

Siblings

Other

Do you have frequent sinus infections?

Yes No

How many per year?

Are you exposed to smoke?

Yes No

Do you smoke?

Yes No

How much?

How long?

Who is your family Physician?

Current Medications?

Are you allergic to any medications?

Yes No

What?

HOME ENVIRONMENT

How long have you lived in the Tri-Cities?

How long in your present home?

Type of home?

Age of home?

Carpeting?

Is there Water/Mildew damage?

Heating/Cooling

Central

Floor Furnace

Weed Stove

Window A/c

Filters

Other

Do you have pets?

Cat

Dog

Other

WORK ENVIRONMENT

Occupation

Do symptoms get worse at work?

Toxic Exposure

Solvents

Chemicals

Fumes

Dust

Mildew

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