Patient name

Allergy, Asthma & Immunology Associates
Patient Name_______________________DOB_______________Date _______________ Appointment Date _____________________Appointment Time______________________ Chief Complaint 1. How did you hear about us? _________________________________________ 2. Who is your PCP? _________________________________________________ 3. Did your PCP (or other Doctor) refer you to us? Y / N If Other Doctor, please specify: ______________________________ 4. What brings you in today? ___________________________________________ 5. How long have you had these problems? _______________________________ 6. Which time of the year is the worst? Spring Fall Summer Winter 7. What do you wish to accomplish with this visit? __________________________ 1. Have you ever been diagnosed with asthma? Y / N 2. How old were you when your asthma began?____________________________ 3. Are you taking medications for asthma? Y / N If yes, please list __________________________________________________ ________________________________________________________________ 4. Does your asthma wake you up at night? Y / N How often? ________ 5. How often do you use a reliever medication? ____/day ____/week ____/month 6. Have you gone to the emergency room or had an urgent doctor’s visit because of your asthma? Y / N How many times in the past 12 months? __________ 7. What is your asthma triggered by? Allergies ____ Exercise ____ Irritants ___ cold weather___ Respiratory tract infections____ Other _________________ 1. Do you have frequent sinus infections? Y / N 2. How many infections have you had in the last year that were treated with antibiotics? Please list which antibiotic was most helpful and date the last antibiotic was taken _______________________________________________ ________________________________________________________________ 3. Is one round of antibiotics sufficient? Y / N 4. Have you been told you have nasal/sinus polyps? Y / N 5. Have you had any sinus CTs recently? Y / N When_______________________ Where ____________________________ 6. Have you had any sinus surgeries? Y / N When?__________________ 1. What type of allergy symptoms do you have?____________________________ 2. How old were you when they began? __________________________________ 3. Have you ever been tested? Y / N 4. What type of test? Blood / Scratch When?______________________ From where can we obtain results?____________________________________ 5. What are your allergies triggered by? Weeds_____ Dust Mites_____ Grasses_____ Foods_____ Other__________________ 6. Have you ever been on allergy shots? Y / N If so, when? __________ How long? _____________ Was shot therapy helpful? Y / N 1. Do you have any known allergic reactions? Y / N 2. Are you allergic to Latex or Rubber? Y / N 3. Have you ever had an allergic reaction from a stinging insect such as a fire ant, wasp, bee, etc.? Y / N Was the reaction local or systemic? ___________ 4. Are you allergic to any medications or foods? Y / N 5. If so, list medications and type of reaction (rash, swelling, wheezing, shortness
Severity of Symptoms: Please (√) rate symptoms when they are active
Symptom None
Moderate
Please list any other medical conditions you may have:_______________________ ___________________________________________________________________ Have you had any surgeries or hospitalizations? Y / N If yes, When? (i.e. Gallbladder 01/03, Tonsillectomy 02/03 etc.) • _______________________________________________________________ • _______________________________________________________________ • _______________________________________________________________ 1. Occupation_______________________________________________________ 2. Marital status: Single 3. Do you have children at home? Y / N If yes, how many? ___________ 4. Do you smoke? Current____ Past_____ Never_____ 5. How long did/have you smoked? _________ How many packs a day ________ 6. If you quit smoking, what year did you quit? _________ 7. Are you exposed to second hand smoke? Y / N 8. Do you drink alcohol? Y / N 9. Do you/have you use/used recreational drugs? Y / N 10. Do/have you use/used IV drugs? Y / N 11. Do you have HIV risk factors? Y / N 12. What is your ethnic background? ____________________ 1. Have you received a pneumonia vaccination? Y / N If yes, when?______ 2. Do you get a flu shot every year? Y / N 3. Are your immunizations up to date? Y / N 4. How many steroid injections and/or oral steroids, such as Prednisone or Medrol dose pack(s), have you taken in the past year? 1-3_______ 3+______ 1. What was the first day of your last menstrual period? __ __/__ __/__ __ 2. Are you pregnant? Y / N 1. Do you have any pets? Y / N What type? Cats_____ Dogs_____ Other _____ 2. Are they: Inside_____ Outside_____ Both_____ 3. Do they sleep in your bedroom? Y / N 4. How old is your home? _______________ 5. What type of flooring is in your living room/bedroom? 6. What type of window covering? Cloth Wood Plastic/Metal Other 7. Do you have ceiling fans? Y / N 8. Is there a fan in your bedroom? Y / N 9. Has there been any water damage to your home? Y / N 10. Was it repaired? Y / N 11. If the patient is a child, does he/she go to daycare? Y / N 12. Are there any disputes/divorce situations that make your child’s care more difficult? Y / N If yes, please describe__________________________ What is your family history of illness? ( please limit to allergy, asthma, eczema, immune deficiency, etc.) -Please list relative(s) and condition(s) • _______________________________________________________________ • _______________________________________________________________ • _______________________________________________________________ Please mark problems experienced in the past 12 months. If yes, describe. 1. Fever? Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________ Y / N __________________________________
Current Meds

List all your current medications (Include over-the-counter medications, eye drops, nose
sprays, multi-vitamins, herbal supplements, hormones, high blood pressure meds, etc.)
Medications Tried Past or Present

Medications continued
Emergency Contact Information Name _________________________________ Relationship ____________________________ Home phone# ___________________________ Work/Cell phone # _______________________ Signature ________________________________ Date___________________________ History reviewed by ___________________________ Date________________________

Source: http://www.aaiadallas.com/docs/patient_questionaire.pdf