Allergy Questionnaire

 

Name ___________________________ DOB:_________ Date: ___________

 

Please fill in the blanks and circle applicable answers. Feel free to add comments. Base your responses on your own observations, not on what you have been told by friends or other physicians. If a parent, please answer for your child.

 

1.      Do you have any of these symptoms? (please circle)

SneezingShortness of breath
Running NoseWheezing
Nasal congestionCough
Ear fullness/stuffinessSinusitis
Itchy eyesHives
Puffy eyesEczema
HeadachesRoom spinning
BronchitisLightheadedness
Otitis MediaImbalance

 

2.      What symptom(s) bother(s) you the most? ________________________________________

 

3.      When did your symptom(s) begin? _______________________________________________

 

4.      In which of the following locations do you notice a change in your symptom(s)?  Check any that apply.

IndoorsAt Home
OutdoorsWork

 

5.      Are you worse in a particular season?  Yes     No

 

6.      Which season? Spring   Summer   Fall   Winter   All

 

7.      Have you ever had a severe reaction to food or medication?  Yes   No

If yes to what? ________________________

 

8.      Have you ever had a severe reaction to an insect bite or sting?  Yes  No

 

9.      Have you ever gone to the Emergency Room or been hospitalized due to an allergic reaction? Yes  No

Do you know what caused the reaction? ____________________________________

 

10.  Do you have asthma?____________________________________________________

a.      Is it intermittent?__________________________________________________

b.      Exercise Induced?__________________________________________________

c.       Well-controlled with meds? Yes   No    If Yes, which meds?_________________

d.      Pulmonologist/ Physician who is treating? ______________________________

 

11.  Have you ever had an allergy work-up with testing (skin or blood?) Yes   No

By whom and type of practitioner? _________________________________________    

When? _______________________________________________________________  

Any complication(s) with testing? __________________________________________

 

12.  Have you ever taken allergy shots?  Yes  No

When? ______________________ How Long?  __________________________________________

If you have previously, why did you stop? _______________________________________________

 

13.  What is your occupation? ___________________________________________________________

Do you come in contact with dust or dirt?  Yes   No

with chemicals?    Yes   No

with animals?        Yes   No

 

14.  Do your symptoms cause problems/discomfort at work?

If yes, please describe______________________________________________________________

 

15.  Do you have any pets?  Yes No

Types___________________________________________________________________________

 

16.  How long have you lived in Chicago? __________________________________________________

 

17.  Where do you live? (circle all that apply)

City    Suburbs     Rural     House    Apartment

How old is your place of residence? ________________________________________________________________________________

 

18.  Are you allergic to any foods?

Which foods? ____________________________________________________________________________

What happens? ____________________________________________________________________________

 

19.  Are you allergic to any medications?    Yes    No

Allergy to Penicillin? Yes    No

Other medications? ___________________________________________________________

What type of reaction occurs? _______________________________________________________________

 

20.  Do you get skin reactions from detergents, soap, lotions, perfumes?  Yes       No