Allergy Questionaire Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 9How were you referred?PhysicianGoogleFacebookInstagramInsuranceOtherWhen did your symptoms begin? NextAre your symptoms getting worse?YesNoDo you have any of these symptoms?CoughRunny NoseNasal PolypsEczemaWheezingNasal CongestionPoor Sense of SmellHivesShortness of breathItchy NoseEar InfectionsHeadachesChest tightnessItchy / Watery EyesSinus InfectionsSnoringSneezingPostnasal DripBlocked EarsFatiguePhlegm /Sputum (color)OtherPreviousNextCheck any of the following which seem to trigger (or cause) symptoms or bother you:GrassCatsCosmeticsDraftsNervousnessHayDogsAerosol spraysHouse dustCold AirMold and MildewHorsesPerfumesSmokeHumidityBasementsOther animalsInsecticidesPollutionWeather changesLeavesAlcoholic beveragesOdorsExerciseLatex (rubber)OtherPlease ExplainPreviousNextWhen are your symptoms worse?Year RoundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberPreviousNextAre symptoms better away from home?YesNoIf Yes, when?Have you been skin tested?YesNoResults:PreviousNextHave you had allergy injections?YesNoIf yes, when?Have you received cortisone (prednisone, methylprednisolone, etc.) drugs?YesNoIf yes, for what condition:Occupation (current or former)PreviousNextYOUR PAST MEDICAL HISTORYCheck all that apply:DiabetesLiver disease/hepatitisPeptic ulcerHeartburn/Acid refluxCancerHeart problems/murmurThyroid diseaseSeizuresHigh blood pressureOsteoporosisArthritisMigrainesAnemia/blood disorderAsthmaHay feverDepressionKidney/bladder diseaseGynecologic problemsDiarrheaAnxietyBack problemsGlaucomaCataractsLoss of hearingEmphysemaIf yes to any of the above, please explain:Have you had your tonsils or adenoids removed?YesNoHave you had ear, nose or sinus surgeryYesNoIf yes please explain:PreviousNextFAMILY HISTORYWho in your family has had: (NOT including yourself)AsthmaEczemaSeasonal /year-round allergiesOther allergies (drugs/bee sting/food etc)Sinus problemsPlease list any hospitalizations regardless of cause:List any potential food allergies and reactions experienced:List any drug allergies and reactions experienced (i.e. penicillin, aspirin, sulfa, latex, etc.):Describe any reaction to insect stings:List all medications and dosages (including nasal sprays, non-allergy medications and alternative/herbal products):PreviousNextLayoutPatient Name: *Email *Date *PhoneWe look forward to reviewing your history and taking care of your family’s allergy needs. We will contact you after our review.Please list your preferred means of communication:PreviousSubmit
