Allergy Medical Group, Inc
 
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Allergy & Health Questionnaire:
Please complete this Questionnaire ASAP! We will need this at least (1) week before your visit. Give your best guess if you cannot remember all of the details.
Your Name:
Sex:
Male: Female:
Date of Birth:
Marital Status:
Single Married Divorced:
Age:
   
1) In your own words, please describe the most urgent or important problems or symptoms ( up to a mazimum of 3 ) which have prompted your visit:

2) Where have you resided in the past?
1st Previous Address:
Street Address:
City / State / Zip Code:
Years at Residence:
2nd Previous Address:
Street Address:
City / State / Zip Code:
Years at Residence:
3rd Previous Address:
Street Address:
City / State / Zip Code:
Years at Residence:

3) Please list all drug allergies or intolerance below:
Drugs/ Agents:
Type of Reactions:
How Soon After Taken:

4) List all food reactions:
Food:
Type of reactions:
How soon after eaten?
5) List medications (including the doses) or treatment taken currently or in the past for your allergic conditions: (notate the medications you consider effective).


6) List all significant past or current medical conditions and the medications, if any, currently required for each: (Including medical devices such as CPAP for Sleep Apnea).
Medical Conditions:
Medications / Treatment
Year First Diagnosed:

7) List any herbal, mineral or vitamin supplements you are currently taking:
8) List any allergy skin testing or allergy shots received in the past:
Year skin tests done: Duration of allergy shots:
Effective?

Name & address of allergist?

9) List all past surgeries & conditions requiring hospitalizations below:


10) Health screening: (Please choose applicable items and enter the date of onset below)
How do you usually feel on waking up in the morning?
Tired:    Average    Feeling Refreshed    Energetic    Depressed    Anxious:   

If female, date of last menstrual period: Are you pregnant? Yes: No:
How many days of school or work have you missed in teh past year?
Weight Gain/Loss in the past 6 months in lbs.?
 
(The following items should be selected only if they accur more than 2 times a month or are chronic)
Headaches: Dizziness Spinning Vertigo Numbness
Tingling Trouble falling asleep Waking up frequently at night Teeth grinding
Sleep apnea Loud snoring Stop breathing at night Marital Problem
Job Problem Smelling/taste impairment Frequent nosebleeds Frequent throat clearing
Hoarseness sore throat Blurred vision Double vision
Glaucoma Chest Pain (with breathing, eating, exercise) Irregular heart beats Change in bowel habits
Frequent heart burns Acid reflux Nausea Vomiting
Diarrhea Constipation Frequent joint/muscle ache Fingers/feet sweeling
Urination: Burning: Increased frequentcy: Slow stream:
Genital: Abnormal periods: Frequent vaginitis/prostatitis Prostate problem

11) Tobacco/Marijuana smoking:
None:
  
Used To:
  
Currently:
  

12) If you are taking any recreational drugs such as cocaine, please enclose a list in a separate envelope.
 
13) Sexual Preferences With:
opposite sex    same sex:    both sexes    abstained:   

14) Environmental History:
Pets:
Indoor/Outdoor
Years Kept:
Any Adverse reactions on contact?

Type of heating / air conditioning system in the house?   Gas:    Electric:    Solar:   

Choose Items in you bedroom already encased in a mite-proof cover?
Mattress:    Box Spring    Pillows:    Comforter:    Water Bag:   

Any water damage/mold infestation at your current or recent home?   Yes:    No:   

If so, when was it first detected?
Was the problem fixed?
Date Moved Out?

15) Factors affecting your symptoms: Place an (X) in the space if worse & (B) if better:
 
Eyes
Nose
Chest
Others
Strong Scents:
Humidity:
Tobacco Smoke:
Weather Changes:
Menses:
Seasons:
Pets:
Cut Grass/Golf:
Indoors:
Outdoors:
Windy Days:
Stress:
Smog:
Out of State:


16) Immunization History: Enter date of the latest vaccination:
TD (every 10 years):
Pneumococcal (lifetime except in splenectmy):
Hepatitis A (2 doses):
Hepatitis B (3 doses):
Smallpox:
Polio:
MMR:
Combined Hep A & B:
Others:

17) Family History: Please check or enter the information below:
Family Members:
Age:
Hay Fever:
Asthma:
Eczema:
Chronic Sinusitis:
Frequent Headaches:
Chronic Cough
Heart Burns:
Other Significant Illnesses:
*Paternal Grandfather :
Paternal Grandmother :
**Maternal Grandfather :
Maternal Grandmother :
Mother :
Father :
Brothers :
Sisters :
Sons :
Daughters :
*Paternal : Father's Side
**Maternal: Mother's Side

Any other information you wish to share with us?