ࡱ>  vbjbj <{{-  HH8L4h`bbbbbb$7QaނaaHHdavH<`a`J.\|ׄlL0}4"փ_aaaa :  Allergy Questionnaire Date: ______________________ Name: ____________________________________ Sex: M _____ F_____ Date of Birth: ____________________________________ Consulting Physician - Please fill out the information below if you have a referring physician. Doctors Name: _______________________________________ Phone: ______________________ Address:_____________________________________________ Fax: ______________________ Reason for your visit What is the main reason for your visit to our Allergy and Immunology clinic? How long have you had this problem? ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Please list the approximate dates and findings of any previous allergy testing and evaluation: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ If you have received allergy injections in the past, please list the years you received them: ____________________________________________________________________________________________________________ Past Medical History Birth Weight and Gestational Age (40 weeks is full term) _____________________________________________________ Have you had the following diseases or conditions? (If yes, when did it start?) Yes No Illness at birth ___ ___ ____________________________________________________________ Whooping Cough ___ ___ ____________________________________________________________ Croup ___ ___ ____________________________________________________________ Diabetes ___ ___ ____________________________________________________________ High Blood Pressure ___ ___ ____________________________________________________________ High Cholesterol ___ ___ ____________________________________________________________ Cataracts or glaucoma ___ ___ ____________________________________________________________ Thyroid disease ___ ___ ____________________________________________________________ Heart Disease ___ ___ ____________________________________________________________ Heartburn or reflux ___ ___ ____________________________________________________________ Osteoporosis ___ ___ ____________________________________________________________ Liver disease ___ ___ ____________________________________________________________ Kidney disease ___ ___ ____________________________________________________________ Other medical problems not mentioned above: ______________________________________________________________________ Infection History Circle if yes: blood infection, bronchitis, pneumonia, sinusitis, chickenpox (or varicella vaccine), hepatitis, HIV, ear infections, meningitis (brain infections), sexually transmitted disease, shingles (zoster), urinary tract infection Other: __________________________________________________________________________________________ Previous Hospitalizations/Surgeries/Emergency Department visits Year Procedure or Reason for hospital or Emergency Department visit ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Drug Allergy: Please briefly describe any known allergies to drugs below. % Penicillin: ______________________________________________________________________________________________ % Sulfa drugs: _____________________________________________________________________________________________ % NSAIDs (aspirin, ibuprofen (Motrin, Advil), naproxen, etc.) ______________________________________________________ % Other: _________________________________________________________________________________________________ % None (I am unaware of any drug allergies)  Family History MotherFatherBrotherSisterSonDaughterOthers Seasonal Allergies (Hay Fever)__________________________________________Asthma__________________________________________Eczema__________________________________________Immune deficiency__________________________________________Other Diseases: (1) ______________________ ______ ______ ______ ______ ______ ______ ______(2) ________________________________________________________________ Social & Environmental History (Please circle when appropriate) What pets or animal exposure do you have? ____________________________________________ Do you smoke? YES NO: If Yes, age when you started? ______________________________________________ If No, have you ever smoked? YES NO Quit? ________________________________ Is there anyone at home who smokes? YES NO Where? INSIDE OUTSIDE Do you drink alcohol? YES NO: If Yes, how often and how much? ______________________________________ How long have you lived in Virginia? _______________ Type of home: Single house Townhouse Apartment Mobile Home Dorm Location of home: City Suburb Rural Type of heat: Heat pump, Baseboard, Gas, Oil, Electric, Fireplace, Wood-burning stove, Kerosene space heaters Do you have any: water damage, fire damage or excess mold or mildew? In the bedroom, do you have: wall to wall carpeting, air conditioning, air filters, or wood flooring? What type of work do you do? Or, if you are a student, please tell us what grade/level of education: ________________________________________________________________ Is your work/school related to the problem you are here for today? Yes No How often were you absent from work or school during the last 12 months due to the health problem(s) you are being seen for? ______________________________________ Current Medications Include all prescribed & over-the-counter medications, vitamins, dietary supplements, antacids, Tylenol, Advil etc. NAME  DOSE HOW MANY TIMES PER DAY LENGTH OF TIME TAKEN Pharmacy Name & Phone Number: _____________________________________________________  Allergy History Foods: Yes No Reaction or Symptoms: Tree nuts (ex. walnuts, pecans, almonds) ___ ___ ______________________________________________ Peanuts ___ ___ ______________________________________________ Fish ___ ___ ______________________________________________ Shellfish (shrimp, crab, lobster) ___ ___ ______________________________________________ Milk ___ ___ ______________________________________________ Egg ___ ___ ______________________________________________ Wheat ___ ___ ______________________________________________ Soy ___ ___ ______________________________________________ Melons, Bananas ___ ___ ______________________________________________ Apples, Peaches, Cherries ___ ___ ______________________________________________ Other: _______________________ ___ ___ ______________________________________________ Animals/Bee stings: Yes No Reaction or Symptoms: Cats ___ ___ ______________________________________________ Dogs ___ ___ ______________________________________________ Horses ___ ___ ______________________________________________ Bee Stings (i.e. bees, wasps/hornets, fire ants) ___ ______________________________________________ Other: _____________________ ___ ___ ______________________________________________ Other Substances Yes No Reaction or Symptoms: Latex ___ ___ ______________________________________________ Nickel, other metal: _______________ ___ ___ ______________________________________________ Radiocontrast dye ___ ___ ______________________________________________ Other: _____________________ ___ ___ ______________________________________________ Review of Symptoms Yes No Constitutional Have you experienced weight loss? ____ ____ Do you have recurrent unexplained fevers and/or chills? ____ ____ Eyes Do you have watery or itchy eyes? ____ ____ Do you have burning, redness or discharge? ____ ____  Review of Symptoms , continued Yes No ENMT Do you have ear pain or pressure? ____ ____ Do you have sinus pain or pressure? ____ ____ Do you have loss of smell? ____ ____ Do you have lip swelling or tongue swelling? ____ ____ Do you have a constant sore throat? ____ ____ Heart Do you have skipped beats or palpitations? ____ ____ Do you have chest pain or tightness? ____ ____ Do you have any loss of consciousness or black-outs? ____ ____ Respiratory Do you have a persistent cough? ____ ____ Do you wheeze? ____ ____ Have you ever coughed up blood? ____ ____ Do you have shortness of breath? ____ ____ At rest? ____ ____ With exercise? ____ ____ Wakes you up from sleep? ____ ____ Gastrointestinal Do you have heartburn or reflux? ____ ____ Do you have abdominal pain? ____ ____ Do you have vomiting or diarrhea? ____ ____ Do you have any bloody stools or black tarry stools? ____ ____ Genitourinary Do you have painful or unusually frequent urinations? ____ ____ Do you have any blood in urine? ____ ____ Musculoskeletal Do you have any joint swelling? ____ ____ Do you have any joint pain or muscle aches? ____ ____ Skin Do you have any skin rashes? ____ ____ Do you have any swelling or hives? ____ ____ Do you have any itching? ____ ____ Do you have any dryness or cracking? ____ ____ Neurologic Do you have migraines or headaches? ____ ____ Do you have any dizziness or ringing in ears? ____ ____ Do you have any visual changes? ____ ____ Psychiatric Are you bothered by depression or anxiety? ____ ____ Endocrine Have you become unusually thirsty recently? ____ ____ Do you sense room temperature differently from others? ____ ____ Hematologic/Lymphatic Do you tend to bruise or bleed easily? ____ ____ Do you feel weak and tired easily? ____ ____ Do you have any swollen lymph nodes? ____ ____ Immunologic Do you get frequent infections requiring antibiotics? ____ ____ Patient/Parent/Guardian Signature: Date: (Please Stop Here) Allergy Questionnaire Reviewed by: _____________________________________ MD  Date: ________________      PAGE  Andrew S. Kim, MD Ahmed T. Butt, MD Julie T. Cooper, MD Shahab S. Virani, MD 8140 Ashton Ave, Ste 110 Manassas, VA 20109 Ph: 703.844.0440 Fax: 703.844.0445 Allergy & Asthma Centers Board Certified Pediatric and Adult Allergy & Immunology www.AllergyAsthmaDoctors.com 1500 Dixon St, Ste 203 Fredericksburg, VA 22401 Ph: 540.371.6810 Fax: 540.371.9154 9010 Lorton Station Blvd, Ste 210 Lorton, VA 22079 Ph: 703.339.1660 Fax: 703.372.5567 Please complete this questionnaire and remember to bring it with you for your first visit. The purpose of this questionnaire is to obtain the most complete and accurate history of your allergy problems. Many of the questions may not deal directly with your specific problem, but please answer all the questions which pertain to you and your general health. If you have x-rays, CT scans or laboratory tests that relate to your health problem(s), please bring them with you to your appointment or have your doctor send them to our office prior to your appointment. 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