Deborah J. Freehling, Md, Inc. Allergy History Questionnair E

Transcript

DEBORAH J. FREEHLING, M.D., INC. Board Certified Ear Nose & Throat · Allergy · Head & Neck Surgery · Facial Plastic Surgery 2204 Grant Road, Suite 102 · Mountain View, CA 94040 · Phone (650) 969-2270 · Fax (650) 962-9889 www.SiliconValleyENT.com ALLERGY HISTORY QUESTIONNAIR E Name _______________________ Referred by ______________________ Date _____________ Address ____________________________________________________________________________ Telephone (H) ________________ (W) ________________ Employer ________________________ Birthday ________________ Age ___________ Marital Status _______________________ Insurance Information: Name of Insured ___________________________________________________ Employer of Insured __________________________________________________________________ Insurance Company ________________________________ Insurance ID# _______________________ Please study carefully each question and answer it as best as you can: Cough? Constant _____ Intermittent _____ Daytime _____ Frequent colds or Upper Respiratory Infections? ______ Nighttime _____ As a child? _____ Temperature with colds? _____ Sneezing? _____ What might precipitate it or increase it? _________________________________ Is it seasonal or related to location? _____________________ Sore Throats? Frequency? ____________________________________ From infections? Yes _____ No _____ From drainage? Yes _____ No _____ Nose Drainage? From the front or down the throat? Circle one. Drainage clear or colored? Thick? _____ Thin? _____ From right side _____ From left side? _____ Both _____ Nose Blockage? Right side? _____ Eye Symptoms? Itching? Burning? Yes _____ Left side? _____ Watering? No_____ Both? _____ Puffy? Circle one Where? Inside corner _____ Outside _____ All over? _____ 2 Headaches? Which part of the head? __________. What starts a headache? _____________________. What makes it worse? _______________ Is headache worse at any certain time of day? __________. Can you tell when a headache may be starting? ________ How? ______________________________. Fatigue? ________ When? _______________ Certain times of the day? _____________________ Before eating? __________ After? _________ Certain days of the week? ____________________ When? _______________ Chronic? _______________ Shortness of breath? _________ Do you know why? __________________________ Explain _____________________________________________________________________________ Wheezing? _______ Now? _________ Out in the cold? _______ As a child? ________ With exercise? _________________ With infections? ________ Other things the may cause your wheezing? _______________________________________________________ Asthma? _________ Now? _______ As a child? ______________________ As a child did you have frequent urinary tract infections? _____________________________________ Do you have “sinus problems”? ______________________________ Earaches? _______ Do your ears drain or run? _____ If so, clear or cloudy drainage? __________ Do you experience any of the following sounds or sensations? Itchy? _____ Stuffy? _____ Flaky? _____ Ring? _____ Buzz? _____ Crackle? _____ Pop? _____ Hearing loss? _____ Vertigo (Spinning)? _____ Other sounds? _____ When? ___________________________________ Loss of smell? _____ When? __________________________________________ Loss of taste? _____ When? ___________________________________________ Laryngitis? ___________ Eczema? _____ Now? ____ As a child? _____ Describe type and location _______________________ Hives? _____ When? ________________ Where? _______________ Specify? ________________ _____________________________ Any known material the causes a rash? ______________________ Soap? _____ Ointments? _____ Paints? _____ Clothing? _____ Cosmetics? _____ 3 Poison Ivy? _____ Fungus infections? _____ Athletes foot? _____ Vaginitis? _____ Jock rash? _____ Do you currently have premenstrual syndrome (female)? __________________________ Do you have acne? ______ Have you ever been diagnosed as having ENDOMETRIOSIS (female)? ___________________ Pets? _____ Kind? __________ Keep inside or out? ______ Breed? ________ How long have you had your pet? _______ Symptoms worse when visiting friends who have pets? _________________ Animal contact that causes symptoms? ____________________________ Do you smoke? _______ Cigarettes? _____ Cigars? _____ Pipe? _____ Snuff? _______ Chew tobacco? ________ If you do not smoke, does someone else’s smoke bother you? __________________________ Do you perspire excessively? _________________________ Do you regard yourself as being nervous? __________________________________________ Problem with personality or behavioral changes? _________ Certain times of the day? _________ Explain _____________________________________________________________________________ Certain seasons? _________________ With certain foods? _______________________________ Itchiness? _____________ Nose? ____________ Roof of mouth? ____________ Hands? _____________ Feet? ____________ Ears? _______ Were you a premature baby? __________ As an infant, were you taken off formula or any foods? ___ _________________________________ Specify _________________________________________ Were you a colicky of fussy baby? _______ Breast or Bottle fed? ______________________________ Have you ever experienced anxiety or panic attacks? ______ Are you being treated? ___________ Do you suspect any food of increasing your symptoms? _______ Specify? ______________________ Do you have any specific cravings or do you overindulge in certain foods? ______ List: _______________________________________________________________________________ 4 Does any certain food give you indigestion, hives, otherwise upset you? _______ Specify? __________ _______________________________________ Do you have irritable bowel? __________________ Do you have excess gas without eating gaseous foods, such as fiber, beans, cabbage, etc.? ___________ Are you awakened during the night with any symptoms? ________ Headaches? _____ Bloating? _____ Stomach cramps? _____ Dizziness? ______ Which Symptoms? Thirst? _______ Heartburn? _______ Dry cough? _______ Sore throat? ______ Do you awaken in the morning with any symptoms? Joint pain/stiffness? _____ Increased congestion? _____ Increased drainage? _____ Nausea? _____ Other? ___________ Do your symptoms increase or decrease with the following conditions: INCREASE DECREASE SAME __________ __________ ______ Cold weather __________ __________ ______ Warm Weather __________ __________ ______ Air Conditioning __________ __________ ______ Windy Days __________ __________ ______ March to May __________ __________ ______ May to July __________ __________ ______ August to October __________ __________ ______ November to March __________ __________ ______ Damp Weather __________ __________ ______ Housework (dusting, etc.) __________ __________ ______ High pollution levels __________ __________ ______ Change of seasons __________ __________ ______ When furnace goes on __________ __________ ______ Going to bed __________ __________ ______ After asleep for a short time 5 INCREASE DECREASE SAME __________ __________ ______ Upon rising __________ __________ ______ Later in the day, 4-9 pm __________ __________ ______ Being in or mowing grass HOME AND WORK ENVIRONMENT (Please Specify by H for Home and W for Work) What is your occupation? _______________________________________________________________ Do you participate in any particular activities, hobbies, or recreation? _________ Please specify: _______________________________________________________________________________. Are your symptoms increased at home, work or no change? ___________________________________ Are you exposed to excessive amounts of dusts, fumes, chemicals, noise? ________________________ Are there plants, dried flowers, fresh flowers at home or work? _________________________________ HEATING SYSTEM: (HOME AND WORK) Electric _____ Gas ________ Oil ______ Propane ________ Kerosene heater _________ Forced air _____ Fireplace ______ Wood burning stove _______ Hot water _____ Coal burning stove _____ Air conditioning _______ COOKING: Gas _______ Electric ________ Air cleaner ______ Humidifier ________ Propane _______ LAUNDRY: Do you use softener sheets, liquid softener, or bleach in the laundry? Circle one COSMETICS: Do you use makeup? ________ Eye make up? _______ Perfume? ________ Aftershave? ________ HOUSING: Do you live in a house? ________ Two story? _______ Split level? ________ Ranch? ________ Trailer? _______ Do you live in an apartment? _________ Older building? _______ Small building? ________ Newer building? _______ Large building? ________ 6 Have you had insulation blown into your house? __________________________________ FURNITURE: Upholstered? ___________ Not upholstered? ____________ Fabric? ________ Vinyl? __________ Other? (What)? ___________ FLOOR COVERINGS: WALL COVERINGS: _____ Carpeting and pads _____ Wall paper _____ Carpets and pads _____ Fabric _____ Rugs and pads _____ Paneling _____ Throw rugs _____ Tapestries _____ Linoleum _____ Pennants MATTRESS: WINDOW COVERINGS: _____ Innerspring _____ Washable curtains/drapes _____ Waterbed _____ Unwashaable curtains/drapes _____ Foam rubber _____ Shades _____ Other (specify) _____ Blinds ___________________ _____ Others BEDS AND BEDDING: PILLOWS: _____ Number of beds _____ Feather or down _____ Comforters _____ Foam rubber _____ Chenille bedspread _____ Kapok _____ Stuffed animals _____ Dacron or polyester Do your symptoms improve, get worse or stay the same when on vacation? Circle one. Where do you usually go on vacation? Mountains, Seashore, other ______________________________ 7 FAMILY HISTORY: FATHER MOTHER BROTHER SISTER CHILD ________ ________ _________ _______ ______ FATHER MOTHER BROTHER SISTER CHILD Emphysema ________ ________ _________ _______ ______ Hay Fever ________ ________ _________ _______ ______ Sinus Problems ________ ________ _________ _______ ______ Hives ________ ________ _________ _______ ______ Postnasal ________ ________ _________ _______ ______ Drainage ________ ________ _________ _______ ______ Eczema ________ ________ _________ _______ ______ Thyroid Problems ________ ________ _________ _______ ______ Food Allergies ________ ________ _________ _______ ______ Bronchial Asthma How long have you had specific symptoms that brought you to our office? Months ________ Weeks _________ Years _______ Days _________ Have you had allergy testing before? __________ Doctor who performed the tests: _______________________ Date of last testing: ___________ Address: ______________________ Type of testing: Scratch, Intradermal, RAST (circle one) Were there positive reactions? __________ To what? ________________________________________ Were you treated? ____________________ For What? _______________________________________ With injection? _________ Medication? __________ Other treatment? ______________________ How long? _____________ Did you improve with treatment? ________________________________ 8 MEDICAL HISTORY Present illness or symptoms: ____________________________________________________________ Illnesses treated for in the past 5 years: ____________________________________________________ LIST ALL MEDICATIONS YOU ARE TAKING NOW: _____________________________________ ___________________________________________________________________________________. List any allergies to any medications: _____________________________________________________ List all operations you have had: _________________________________________________________ When was your last chest x-ray? ___________________________ Result? _______________________ When was your last EKG? _______________________________ Result? ______________________ When was your last stress EKG? ___________________________ Result? _______________________ Have you ever had? (check) if yes ( ) Head injury ( ) Liver disease ( ) Major injuries ( ) Cancer (of _________) ( ) Eye problems ( ) Diabetes ( ) Lung/Breathing problems ( ) Thyroid problems ( ) Coughing up blood ( ) Kidney or urinary problems ( ) Heart/Circulatory problems ( ) Arthritis ( ) High blood pressure ( ) Epilepsy or seizures ( ) Stomach or intestinal problems ( ) Emotional problems ( ) Easy bruising ( ) Bleeding or Blood problems ( ) Gallbladder problems ( ) Vomiting or passing blood in stools Explain all YES answers and describe any other problems: _____________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Have you had any steroids (cortisone) in the past month? _____________________________________