my allergy history - sinus doctor | sinus center...
TRANSCRIPT
Symptoms: Please mark which symptoms you have or have had in the past year.
ALLERGYCLINIC
Idaho
Allergy logo • 8.22.03
my allergy historyName__________________________________________________________
Today’s Date____________________
NASAL / SINUS n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Nasal congestion o o Headaches o o Snoring o oRelieved by decongestants o o Bad breath o o Nose bleeds o oNot relieved by decongestants o o Unpleasant taste o o Rubbing of nose o oItching o o Facial discomfort o o Loss of sense of smell o oSneezing o o Clear discharge o o Recurrent sinus infections o oRunny Nose o o Thick discharge o o Fatigue o oPost nasal drainage o o Mouth breathing o o Loss of sleep o o
EYES n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Itching o o Burning o o Dark circles o oWatery o o Puffy/Swollen o o Other: ___________________________
THROAT n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Itching o o Recurrent sore throat o o _________________________________
Loss of voice o o Chronic sore throat o o _________________________________
EARS n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Popping o o Dizzy o o _________________________________
Hearing loss o o Infections o o _________________________________
COUGH n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Continuous o o Barking o o With Sputum o oDay time o o Interferes with sleep o o Deep o oNight time o o Dry with no sputum o o Exercise makes worse o o
FOOD ALLERGIES n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Foods causing: Allergic reaction o o Hoarsenes o o Wheezing o oItching of mouth o o Change of voice o o Shortness of breath o oSwollen tongue o o Cough o o Loss of consciousness o oSwollen lips o o Hives o o Light headed o oItching of throat o o Nausea or vomiting o o Palpitations o oTightness of throat o o Diarrhea or cramps o o
Patients Initials__________PAGE 1 OF 7
FREQUENT INFECTIONS n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Chronic infections o o Recurrent Infections o o Skin Rashes o oIncomplete clearing o o Poor response to o o Growth failure o o of infection treatment Diarrhea o oONSETPlease check the specific symptoms and the season when it occurs/is worse. Leave blank if the specific symptom is not a problem.
Spring Summer Fall Winter Arising Morning Afternoon Evening Night
Wheeze o o o o o o o o oCough o o o o o o o o o
Shortness of breath/Chest tightness
o o o o o o o o o
Nasal stuffiness o o o o o o o o oNasal itching o o o o o o o o o
Sneezing o o o o o o o o oEye symptoms o o o o o o o o o
Throat symptoms o o o o o o o o oFatigue o o o o o o o o o
Animals n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Cats o o Dogs o o _________________________________
AGGRAVATING FACTORS: Please mark what makes your symptoms worse.
WEATHER n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Cold o o Humidity o o Temperature Changes o oHeat o o Air Conditioning o o Weather Changes o o
INFECTIONS n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Colds o o Sinus Infections o o _________________________________
IRRITANTS n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Dust o o Non-chemical odors o o Pollution o oPerfumes / scents o o Chemical fumes o o Smoke o oACTIVITIES n Yes n No (if no, go to the next section)
YES NO YES NO Other: ___________________________
Gardening o o Raking Leaves o o _________________________________
Mowing grass o o Exercising o o _________________________________
LOCATION n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Work o o Home o o _________________________________
School o o Farm o o _________________________________
Patients Initials__________PAGE 2 OF 7
MEDICATIONS n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Pain medications o o Blood Pressure (ACE inh.) o o Aspirin o oBeta blockers o o Eye drops o o Topical decongestants o o
OTHER n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________
Foods o o Pregnancy o o _________________________________
Menstrual cycle o o Psychological factors o o _________________________________
TRAVEL n Yes n No (if no, go to the next section)YES NO YES NO YES NO
Salt air o o Mountains o o Urban areas o oHumidity o o Desert o o Rural areas o o
CURRENT ENVIRONMENT n Yes n No Type of home _________________________________________________________________________________
Age of home _________________________________________________________________________________
Time at current residence _________________________________________________________________________________
WORK ENVIRONMENT YES NO YES NO YES NO
Office o o Farm o o Daycare o oFactory o o School o o Other:_____________________________
Outdoors o o Health Care Facility o o ___________________________________
HEATING/COOLING YES NO YES NO YES NO
Electric o o Kerosene o o Air Conditioner o oGas o o Wood Stove o o Swamp Cooler o oOil o o Forced Aire o o HEPA Filter o oPropane o o Hot water o oAGRICULTURAL EXPOSURE
YES NO YES NO YES NO
Hay o o Alfalfa o o Corn o oWheat o o Potatoes o o Other_____________________________
Sugar beets o o Livestock o o __________________________________
COOKING YES NO YES NO YES NO
Gas o o Electric o o Propane o oFLOOR COVERINGS
YES NO YES NO YES NO
Wood o o Linoleum o o Carpeting, no pads o oTile o o Carpeting & Pads o o Rugs o o
Patients Initials__________PAGE 3 OF 7
AGGRAVATING FACTORS (continued): Please mark what makes your symptoms worse.
YOUR ENVIRONMENT:
WALL COVERINGSYES NO YES NO YES NO
Wall paper o o Paneling o o Sheetrock o oFabric wall “paper” o o Tapestries o o Plaster o o
WINDOW COVERINGSYES NO YES NO YES NO
Washable curtains/drapes o o Shades o o Vertical Blinds o oUnwashable curtains/drapes o o Horizontal blinds o o Other_____________________________
YOUR BEDROOM YES NO YES NO YES NO
Bare floors o o Curtains o o Down comforter o oBare floors with rugs o o Blinds o o Chenille bedspread o oCarpeting o o Stuffed animals o o Other_____________________________
FURNITURE YES NO YES NO YES NO
Wood o o Fabric upholstery o o House plants o oMetal o o Leather upholstery o oPlastic o o Vinyl upholstery o o
YOUR MATTRESS YES NO YES NO Other_____________________________
Innerspring o o Foam rubber o o __________________________________
Waterbed o o Futon o o _________________________________
YOUR PILLOWSYES NO YES NO Other____________________________
Feather or down o o Kapok o o _________________________________
Foam rubber o o Dacron or polyester o o _________________________________
PETSYES NO YES NO YES NO
Outdoor cat now o o Indoor cat in past o o Indoor dog now o oOutdoor cat in past o o Outdoor dog now o o Indoor dog in past o oIndoor cat now o o Outdoor dog in past o o Birds o oOther__________________________________________________________________________________________________________
OTHER FACTORS YES NO YES NO YES NO
2nd hand smoke o o Dampness o o Symptoms with hobbies o oMold or mildew o o Damp basement o o Latex/rubber exposure o oWater damage o o Window condensation o o
Patients Initials__________PAGE 4 OF 7
YOUR ENVIRONMENT (continued):
HAVE YOU BEEN ALLERGY TESTED? n Yes n No (if no, go to the next section)TYPE: YES NO YES NO YES NO
Do not recall o o Prick Test o o IDT o oScratch Test o o SET o o RAST o oOther o o
PREVIOUS TREATMENT:
ALLERGIC TO: YES NO YES NO YES NO
Dust o o Weeds o o Cats o oTrees o o Grass o o Dogs o oMolds o o Other_____________________________
PREVIOUS PHYICIANS TREATMENT n Yes n No (if no, go to the next section)YES NO Helpful Not Helpful
Medications o o o oimmunotherapy shots (weekly) o o o oReaction to shots? o o o o Explain_______________________________________
Steroid Injections (Depomedrol/Kenalog)
o o o o
SET o o o o
NASAL, ALLERGY, & ASTHMA MEDICATIONS Please mark all medications that you are currently or have previously taken.
ANTIBIOTICS PRESENT PAST PRESENT PAST PRESENT PAST
Amoxicillin o o Ceftin o o Omnicef o oAugmentin o o Doxycycline o o Suprax o oAvelox o o Dynabac o o Tequin o oBactim/Septra o o E-mycin o o Vantin o oBiaxin o o Levaquin o o Zithromax (Z-Pack) o oCeclor o o Lorabid o o Other___________ o o
ANTIHISTAMINE/DECONGESTANT COMBINATIONPRESENT PAST PRESENT PAST PRESENT PAST
Allegra D o o Comhist LA o o Semprex D o oClaritin D o o Rynatan o o Trinalin o o
ANTIHISTAMINESPRESENT PAST PRESENT PAST PRESENT PAST
Allegra o o Clarinex o o Periactin o oBenadryl o o Hydroxyzine o o Zyrtec o oClaritin o o Over the counter o o Other___________ o o
Patients Initials__________PAGE 5 OF 7
ASTHMAPRESENT PAST PRESENT PAST PRESENT PAST
Accolate o o Brethine o o Serevent o oAdvair o o Flovent o o Singulair o oAerobid o o Intal-Foradil o o Theophyline o oAlbuterol o o Maxair o o Vanceril o oAtrovent o o Prednisone o o Ventolin/Proventil o oAzmacort o o Pulmicort o o Other___________ o oBeclovent o o QVAR o o _________________
DECONGESTANTSPRESENT PAST PRESENT PAST PRESENT PAST
Entex o o Sudafed o o Other:___________ o o
EYEDROPSPRESENT PAST PRESENT PAST PRESENT PAST
Acular o o Crolom o o Patanol o oClaritin D o o Livostin o o Other:___________ o o
NASAL SPRAYPRESENT PAST PRESENT PAST PRESENT PAST
Astelin o o Flonase o o OTC nasal spray o oAtrovent nasal spray
o o Nasacort o o Rhinocort o o
Beconase o o Nasarel o o Vancenase o oCromolyn nasal spray
o o Nasonex o o Other:___________ o o
HEARTBURN MEDICATIONPRESENT PAST PRESENT PAST PRESENT PAST
Aciphex o o Prevacid o o Zantac o oAntacids (OTC) o o Prilosec o o Other:__________ o oAxid o o Protonix o o _________________ o oNexium o o Tagamet o o _________________ o o
COMPLICATIONS OF MEDICATIONSPRESENT PAST PRESENT PAST PRESENT PAST
Aspirin allergy o o Singing problems o o Speech problems o oFatigue o o Sleep apnea o o Other:__________ o oHearing Loss o o Nasal septal
perforationo o _________________ o o
Nasal polyps o o _________________ o o
Patients Initials__________PAGE 6 OF 7
Nasal Allergies
AsthmaSinus
ProblemsChronic Post Nasal
DrainageHives
Food Allergies
Drug Allergies
Father o o o o o o o
Mother o o o o o o o
Brother(s) o o o o o o o
Sister(s) o o o o o o o
Children o o o o o o o
Grandparents o o o o o o o
Aunt(s) o o o o o o o
Uncle(s) o o o o o o o
Cousin(s) o o o o o o o
Physician Comments________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
___________________________________________________________________________________
Patient Signature__________________________________________________________________
Physician Signature________________________________________________________________
FAMILY HISTORY OF ALLERGY: To the best of your knowledge, mark which family members have the following history.
Patients Initials__________PAGE 7 OF 7