ࡱ> _ <bjbj"z"z 4@f@f% CC8DG,#ss"B"D"D"D"D"D"D"$ %'hh"in*|nnh"CC"f!f!f!nCRB"f!nB"f!f!"f!ROf!.""0#f!'( '(f!'(f!vTf!pDh"h" #nnnn'( :  NEW PATIENT QUESTIONNAIRE To be filled out by the patient or the parent/guardian of the minor child. The following questions will help to determine the cause of your allergy symptoms. It is important to check (%) each question to the best of your knowledge and as accurately as possible. Name: ______________________________________ DOB: __________ Age: ____ Date: _________________________ Date - Last Antihistamine: ___________ Previous Allergy Workup? Year ______ Tested? _____ Immunotherapy? ______ Referring Physician: ___________________________ Please check what applies to you: General: Nose: % Weight: Gain or Loss % Frequent colds % Tired all the time % Discharge Skin: % Clear / Discolored % Rash (where _____) % Thin / Thick % soap % Constant / Seasonal % contact % Itching, rubbing, picking % Hives % Stuffiness (constant / seasonal) % Eczema, boils, infections % Sneezing % Dryness, itching % Sniffling, snoring, bleed % Insect bite reaction % Change in smell Head: Throat: % Headache (where _____) % Sore, itch % Head injury (when ____) % Trouble swallowing Eyes: % Clearing throat, hoarseness % Strain, change in vision % Post nasal drip (clear/ white/ other) % Redness, puffiness, discharge Respiratory: % Itching, rubbing % Wheeze (with rest / with activity) Ears: % Cough (day/ night, with exercise) % Pain, discharge % Dry % Wet % Itch, popping % Chest tightness % Infections, hearing loss % Shortness of breath CONTINUE ! Patient Name ___________________________________ Date:_____________ Symptoms: Symptoms worse: % indoor, % outdoor, % home, % work, % morning, % afternoon, % night Symptoms worse in what season: %Winter, % Spring, % Summer, % Fall Symptoms Triggers: % smoke, % perfume, % hair spray, % paint, % cosmetics, % insecticides, % chemicals, % fumes, % detergent, % hay, % grass, % dust, % damp areas, % animal (specify ________), % food (specify ________), % alcohol, % cold day, % hot day, % windy day, % weather change, % air conditioning, % intense laughing or crying % medication (specify ________________________) Living Accommodations: % House or % Apartment (age of building ____) Present address for ___ years. Location: %city, % suburb, %country/farm. %Recent painting or repairs. Slab/basement: % finished, % dry, % damp, % mildew Flooring: % hardwood in the bedroom, carpet in the bedroom - % wool, % synthetic, padding - % rubber, % ozite, % other Furniture: % new, % mohair Window treatment: % drapes, % blinds, % shades Heating system: % hot air, % hot water, % electric baseboard. Fuel: % gas, % electric, % coal, % oil, % other ___________ Air filters: % fiberglass, % electrostatic, % HEPA, % other _____________ Air conditioning: % central, % window unit. % Humidifier, % Dehumidifier Usual house temperature: _____ Day _____ Night    ">prt ? @ A   M N n ŽŮvrrrrkvffffffffv\hEh(>56 h(>5 h{0h(>h(>h(>5CJ aJ h[(5CJ aJ h_h_CJaJhxCJaJh,h$ h_CJOJQJaJh$ h_CJ(OJQJaJ(h$ CJ,aJ,h CJ,aJ,jh_hV CJUaJ"jh%CJUaJmHnHu"jhbrCJUaJmHnHu  "rt@ A   M N q r V B gd(>$a$gd(>gd_gd,n q r y z  . T V B @T\jvz08RhlD>@VX *,>NR,.FHX\`h(h(>5hjh(>5 h+]h(> h+'Qh(>h!h(>5h(> h~?h(>hEh(>5 h(>5h{0h(>6I @Tz0lD>@X,R,.\gd(>\nfr* ++z,,--L.N.r..*////v00F1gd(>2B`0nf*r** +++++,,z,,,----.L.N.n.r..*/////0v00F1H11111111111222222222¶ױ hpA5htht5CJaJ ht5hGh(>5h"h(>5 h(>5 hthtUhEh(>5hthtCJaJhth(>FBedroom windows open: % day, % night, % winter, % summer Bedding: Mattress - % regular, % synthetic, % waterbed. Mattress cover - % cotton pad, % allergy proof. Box spring cover - % cotton, % allergy proof. Pillows  % feather, % polyester, % kapok, allergy proof. Blanket - % wool, % cotton, % synthetic, % other Comforter - % cotton, % Down, % other ___________. Pets: % cat, % dog, % bird, % other. Frequent contact - % in house, % access to bedroom Infestation: % cockroach, % mouse, % rat Smoking: % patient, % family member, % work, % other Work Environment: Occupation _________________________ % Office, % factory, % outdoor, % other ______________ Exposure: % smoke, % fumes, % chemicals, % other ____________ Medical History: % Emergency room visit or hospital stays in last 12 months. Specify _________________ % Are currently on allergy shots % Previous reaction to allergy shots. Specify ________________________ Past Medical/Past Surgical History: Current Meds(prescribed and over the counter) Patient Name ___________________________________ Date: _____________ Past Medical History: DiseasePatientFather Mother Sibling AsthmaHay FeverEczemaHivesFood AllergyDrug AllergyFrequent/Many InfectionsSinus InfectionEar InfectionBronchitisPneumoniaMigraineOther Significant: ____________________ ____________________ _____ _____ ________ ________ _______ _______ ______ ______ Drug Reactions: Date/Drug ________________Symptoms _______________________Last taken:Latex Food Reactions: Date/Food _______________Symptoms _______________________Can eat now List Past Allergy Meds/Duration/Effect/Reason for stopping Immunizations: Childhood immunizations completed: % Yes % No Last Flu shot __________ Last Pneumovax _________ Reaction to immunizations: % Yes Specify _______________ % No Questionnaire completed by: _________________________________ (Printed Name) Signature: __________________________________     PAGE  PAGE 1 Lourdes Brigida hunter, m.D., F.A.A.A.A.I., f.A.c.a.a.i Diplomate American board of allergy & immunology 170 THOMAS JOHNSON Drive, suite 102 Frederick, MD 21702 Office: (301) 360-0776 FaX: (301) 631-8443 FREDERICK ALLERGY & ASTHMA CENTER, L.L.c. 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