THE ALLERGY GROUP
Joseph J. Callanan, M.D. Neetu Talreja, M.D.
1000 N. Curtis Road, Suite 303 Boise, ID 83706 208-377-4000 208-375-8426 (fax)
www.theallergygroup.com
MEDICAL HISTORY AND ALLERGY SURVEY
NAME_____________________________________________________AGE_____________DATE_________________
NAME OF PERSON COMPLETING FORM IF NOT COMPLETED BY PATIENT_________________________________
NAME OF PRIMARY CARE PHYSICIAN (PCP)___________________________________________________________
NAME OF REFERRING PHYSICIAN (IF OTHER THAN PCP)_______________________________________________
INSTRUCTIONS: YOU MUST COMPLETE THIS FORM. OUR INSURANCE REQUIRES THAT IT BE DONE.
YOU WILL NOT BE SEEN UNLESS IT IS COMPLETED. THERE ARE 7 PAGES. PLEASE COMPLETE ALL
PAGES.
1. CHIEF COMPLAINT: What are the main symptoms which are bothering you?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. NOSE, THROAT AND SINUSES:
Do you or did you ever have nose, throat or sinus problems? Yes____ No____ If yes, answer below, if no, go to #3.
When did you first have trouble with your nasal symptoms? What age were you?____ Season?________________
Check the following symptoms that you are having:
____ sneezing
____ hoarseness
____ itching of the nose or roof of the mouth
____ decreased smell
____ nose rubbing
____ decreased taste
____ clear nasal discharge
____ itchiness inside ears
____ postnasal drip
____ nose bleeding
____ colored nasal drainage
____ snore
____ frequent nose blowing
____ sore throat in the morning
____ nasal stuffiness
____ you clear your throat often
____ mouth breathing
____ heartburn
____ frequent throat clearing
____ wake up with heartburn
____ sore throat
____ belch a lot
____ yellow or green discharge in your throat
Do some of your nasal symptoms occur almost every day throughout the year? Yes____ No____
Are your nasal symptoms worse during any particular season or time of day?
i.e., (1) mild, (2) moderate, or (3) severe (fill in number):
January __________
February __________
March __________
April
__________
May
June
July
August
__________
__________
__________
__________
September __________
October
__________
November __________
December __________
Morning ____ Afternoon ____ Evening ____ Night ____ All ____
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Have you ever had any of the following problems? (Check)
Yes ____ No ____ sinus infection
Yes ____ No ____ nasal polyps
Yes ____ No ____ temporomandibular joint disease (TMJ)
Yes ____ No ____ frequent headaches – Where? front ____ temples ____ eyes ____ back ____
If yes, do you frequently chew gum? Yes ____ No ____ Have you had braces? Yes ____ No ____
Yes ____ No ____ aspirin-induced nasal symptoms
Yes ____ No ____ nasal surgery – When? ____________________ Last? ____________________
Yes ____ No ____ frequent “bad colds”
Yes ____ No ____ frequent tonsillitis – How many times per year? ____________________________
Check one of the following statements that best describes the severity of your nasal symptoms when they are at their
worst?
____ mild
____ severe
____ moderate
____ very severe
How many school or work days have you missed in a year’s time due to these problems?
_____________________________________________________________________________________________
What medicines have you taken to control your eye and/or nose symptoms?
_____________________________________________________________________________________________
Are you taking any of these medicines every day? _____________________________________________________
Generally, how much relief from your symptoms do you get by taking these medicines?
____ Excellent ____ Good ____ Moderate ____ Very little ____ None
What nose drops or sprays are you using? ___________________________________________________________
Have you had a CT scan of your sinuses? Yes ____ No ____ When ______________________________________
3. EARS: Have you ever had any of the following ear symptoms? (Check)
Yes ____ No ____ If no, go to #4.
Yes ____ No ____ frequent ear infections
Yes ____ No ____ are you dizzy?
How many within the past year? ____
Yes ____ No ____ are you lightheaded?
Yes ____ No ____ is your hearing impaired?
4. EYES: Have you had any of the following eye symptoms? (Check)
Yes ____ No ____ If no, go to #5.
Yes ____ No ____ itching
Yes ____ No ____ light hurts your eyes
Yes ____ No ____ redness
Yes ____ No ____ yellow discharge from eyes
Yes ____ No ____ tearing
Yes ____ No ____ eyelid swelling
Yes ____ No ____ dryness
Yes ____ No ____ eyelid irritation
Yes ____ No ____ burning
How often have these symptoms been a problem within the past year?
Circle correct answer: never;
some;
a lot;
extreme.
5. LUNGS: If you do or have had asthma, please answer the questions.
If you have never had wheezing or lung problems, you may skip this question and proceed to #6.
When did you first begin to have wheezing spells? Age? ____ Season? __________
Check the following symptoms you are having:
Yes ____ No ____ mild to moderate wheezing episodes
Yes ____ No ____ severe wheezing episodes
Yes ____ No ____ does this limit your exercise or play?
Yes ____ No ____ during or after exercise?
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Is your wheezing worse during any particular months or time of day? (Mark yes or no)
January __________
February __________
March __________
April
__________
May __________
June __________
July
__________
August __________
September __________
October
__________
November __________
December __________
Morning ____ Afternoon ____ Evening ____ Night ____
With your wheezing do you usually have:
____ fever ____ cough ____ tightness in your chest?
Do you usually have a cold or chest infections when you wheeze?
______________________________________________________________________________________________
Can you have a normal “bad cold” without you then developing chest congestion and wheezing? _________________
How many times during the past year have you had to visit your doctor (or hospital emergency room) because of your
wheezing? _____________________________________________________________________________________
How many times have you been hospitalized due to wheezing?___________________________________________
When were you last in the hospital for this?___________________________________________________________
How many school or work days have you missed this year due to your wheezing?
______________________________________________________________________________________________
What medicines are you taking to control your wheezing? _______________________________________________
______________________________________________________________________________________________
Do you use inhaler(s)? ____ How often? ____________________________________________________________
Which one(s)? __________________________________________________________________________________
Have you required cortisone (prednisone, Medrol, etc.) drugs for control of your wheezing in the past?
Yes ____ No ____
How many times? ____ Date last used: ____________________
Do you ever have any of the following symptoms? (Check)
Yes ____ No ____ frequent coughing spells
Yes ____ No ____ coughing on exertion
Yes ____ No ____ recurrent night cough
Yes ____ No ____ coughing then wheezing
Yes ____ No ____ coughing up mucus (color? __________) Yes ____ No ____ coughing with laughing
Yes ____ No ____ shortness of breath with exercise
Yes ____ No ____ coughing with lying down
Yes ____ No ____ blood in mucus
Yes ____ No ____ coughing with talking on the phone
6. CHEST INFECTIONS:
As an infant or child, did you have asthma? Yes ____ No ____
X-rays: Have you had a chest x-ray within 5 years? Yes ____ No ____
If so: Date of last chest film _______________ Where x-ray obtained _______________
7. ALLERGIC SKIN PROBLEMS:
Have you ever had eczema? Yes ____ No ____ If no, go to #8.
When last? ____________________________________________________________________________________
What parts of your skin were affected? Arms ____ Legs ____ Face ____ Body ____
8. PREVIOUS ALLERGY EVALUATIONS:
Have you ever had an allergy evaluation in the past? Yes ____ No ____ If no, go to #9.
If you have, then complete the following questions:
What age were you when you had your first allergy evaluation? __________________________________________
Which doctor and where? ________________________________________________________________________
If you have had skin testing, to what were you found to be allergic?
____ trees
____ weeds
____ dust
____ grasses
____ molds
____ feathers
____ foods _____________________________
____ others ____________________________
If you have received a series of allergy shots in the past, please give the inclusive dates:
_____________________________________________________________________________________________
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If you are on allergy shots now, how often are you taking them?
What improvement have you (did you) note(d) in your symptoms while on allergy shots:
____ marked improvement (almost complete clearing of your symptoms)
____ moderate improvement ____ no improvement
Did you ever have an allergic reaction to your shots? Yes ____ No ____
If yes, what happened? __________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
9. FACTORS WHICH MAY CONTRIBUTE TO YOUR ALLERGIC PROBLEMS:
In the following questions, 1-7, check the factors that you think will make your nose symptoms or wheezing (asthma)
start or become worse. Otherwise go to #10.
(1) Lungs
______
______
(2)
______
______
______
______
(3)
______
______
______
(4)
______
______
(5)
______
______
______
(6)
______
______
______
______
______
(7)
______
______
______
______
______
Infections
a “viral bad cold”
a respiratory infection
Weather
change in weather
wet, rainy weather
onset of cold weather
being in the wind
Inhalant Allergens
playing in or mowing the grass
musty smells
exposure to house dust
Hormone
menstruation
pregnancy
Physical Factors
air conditioning
cold air
getting up in the morning
Smells
exhausts, fumes
smoke
perfumes, cosmetics
cleaning agents
cooking odors
Miscellaneous
birds
cats
dogs
other animals
feather pillows
Nasal
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
10. INGESTANTS: Do you know of any foods, drinks, or medicines that will make your nose symptoms or wheezing start
or cause it to become worse? (Circle and add items).
Yes ____ No ____ If no, go to #11.
Foods (milk, egg, wheat, nuts, peanut, shellfish, soybean) _______________________________________________
Drinks (beer, wine) ______________________________________________________________________________
Medicines (aspirin) ______________________________________________________________________________
11. DRUG ALLERGY:
Have you ever had an allergic reaction to any of the following drugs?
Yes ____ No ____ If no, go to #12.
____ penicillin
____ tetracycline
____ sulfa drugs
____ “mycins” (erythromycin)
____ aspirin
____ Levaquin, Cipro, floxin
____ Ceclor (cephalosporin)
____ codeine, morphine, Demerol
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Others _______________
_____________________
_____________________
_____________________
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12. INSECTS:
Have you ever had an allergic reaction to an insect? Yes ____ No ____ If no, go to #13.
____ bee
____ yellow jacket
____ fire ant
____ other
____ wasp
____ hornet
____ deer fly
What happened? Local swelling Yes ____ No ____ Hives, swelling, itching over the entire body Yes ____ No ____
Other_________________________________________________________________________________________
When did the last reaction occur? Approximate date ___________________________________________________
______________________________________________________________________________________________
13. ENVIRONMENTAL FACTORS: If does not apply, go to #14.
(1) Location:
(*) Where your symptoms are worse. () where your symptoms are better.
____ indoors ____ outdoors ____ at home ____ at school or at work
____ in air conditioning ____ away from home ____ the same at all locations
(2) Environmental Exposure: Check the following items that best describe your surroundings:
Residence
Bedroom
How long have you lived in your
____ wall-to-wall carpet
present dwelling? ____ years
____ carpets in bedroom, how old ____ ?
Type of mattress? Regular ____ Water ____
Type of pillow?
Dacron ____ Feather ____
Does your mattress or pillow have airtight covers? Yes ____ No ____
Is there mold growing in your house? ____ If yes, where? ___________________________________________
What kind of animals (birds also) do you have? ____________________________________________________
Are they indoors at any time? Yes ____ No ____ How many years? _________________________________
14. PERSONAL-SOCIAL FACTORS: (EVERYONE MUST ANSWER COMPLETELY)
What is your occupation?
Does anyone practice any hobbies or occupations in your home that produce vapors, or dust, or strong odors?
Yes ____ No ____ If yes, what?
Do you smoke cigarettes? Yes ____ No ____ How many cigarettes per day? ____
Did you ever smoke? Yes ____ No ____ How long? ____ years. Average of how many packs per day? ____
Does anyone smoke in your home? Yes ____ No ____ How many persons? ____
Do you abuse alcoholic beverages? Yes ____ No ____ More than 2-3 drinks per day? ____
Do you use illicit drugs (confidential)? Yes ____ No ____
15. FAMILY HISTORY: (EVERYONE MUST ANSWER COMPLETELY)
Living/deceased Living/deceased How many How many
Father
Mother
Brothers? Sisters?
How many
Children?
Does any of your family have any of the following illnesses? (Check)
Hay fever
Asthma
Eczema
Hives
Sinus trouble
Any other illnesses?
Is any family member deceased? ____________________ Cause? _________________________________________
_________________________________________________________________________________________________
Do any illnesses seem to run on your father’s or mother’s side of the family?
_________________________________________________________________________________________________
Diabetes, hypertension, heart disease, stroke, other? _____________________________________________________
________________________________________________________________________________________________
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16.
PAST HISTORY: (EVERYONE MUST ANSWER COMPLETELY)
(1) Have you ever had any of the following illnesses?
____ tuberculosis
____ pneumonia
____ kidney disease
____ ulcer disease
____ rheumatic heart disease ____ diabetes
____ heartburn
____ thyroid disease
____ hypertension
____ cancer
____ radiation therapy
____ blood transfusion
____ kidney stones
____ liver disease
____ high risk for AIDS
____ sleep apnea
(2) What surgery have you had? (tonsillectomy, nasal surgery, etc.). Approximate dates:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(3) Have you had any serious illness or injuries which led to hospitalization?
Yes ____ No ____ List type and year: ___________________________________________________________
__________________________________________________________________________________________
(4) Have you received the Pneumovax vaccine? Yes ____ No ____ Do you know? ____
(5) Do you receive the yearly flu vaccine? Yes ____ No ____ Do you know? ____
Please list all medications you take and the dose, including over-the-counter medications:
(1) _________________________
(6) _________________________
(2) _________________________
(7) _________________________
(3) _________________________
(8) _________________________
(4) _________________________
(9) _________________________
(5) _________________________
(10) ________________________
REVIEW OF SYSTEMS: (EVERYONE MUST ANSWER COMPLETELY)
Do you have any of the following at this time? (Check)
General
Cardiovascular
____ weight loss
____ chest pain
____ chills
____ chest pain with exercise
____ loss of appetite
____ calf pain with exercise
____ fatigue
____ ankle swelling
____ poor memory
____ fall asleep during the day
Endocrine
____ snoring is a problem
____ cold intolerance
____ heat intolerance
Musculoskeletal
____ morning joint stiffness and aching
____ painful, swollen joints
____ muscle tenderness or pain
____ muscle weakness
Kidney
____ trouble starting urine
____ bed wetting
____ burning with urination
____ loss of urine with cough or sneeze
____ frequent urination during the night
Gynecological
____ excess bleeding
____ change in menstrual cycle
Blood
____ bleed or bruise easily
____ swollen lymph nodes
Gastrointestinal
____ nausea
____ vomiting
____ diarrhea
____ change in bowel habits
____ trouble swallowing (food gets stuck)
____ heartburn
____ black bowel movements
____ blood in bowel movement
Neurological
____ weakness/clumsiness
____ tingling, burning, or numbness of extremities
Other
____ lumps or bumps under arms
____ lumps or bumps in breasts
Psychological
____ fearful, anxious
____ excessive worry
____ crying spells
____ trouble sleeping
____ behavior problems
____ depression
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ADULT SLEEP SCALE (AGE 18 AND OLDER)
Are you sleepy during the day? If so, complete the following using the appropriate numbers, 0 through 3:
0 = not sleepy during the day; 1 = slight chance of dozing; 2 = moderate chance of dozing; 3 = high chance of dozing
Chance of dozing
________
________
________
________
________
________
________
________
Situation of dozing/falling asleep
Sitting and reading
Watching television
Sitting inactively in a public place (theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
PEDIATRIC SLEEP SCALE (AGE 2 TO 17) FILL OUT IF THIS APPLIES TO YOU
Complete using 0 = No or don’t know; 1 = Yes
While sleeping, your child
________
Snores more than half the time
________
Always snores
________
Snores loudly
________
Has heavy or loud breathing
________
Has trouble breathing, struggles to breathe
________
Have you seen your child stop breathing during the night? If so, describe ___________________
Does your child
________
________
________
________
________
________
________
________
________
________
________
________
________
________
Tend to breathe through the mouth during the day?
Have a dry mouth on waking up in the morning?
Occasionally wet the bed?
Wake up feeling unrefreshed in the morning?
Have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight? (if so, at what age did this first develop? ________)
Have difficulty organizing tasks and activities?
Is easily distracted by extraneous stimuli?
Fidgets with hand or feet or squirms in seat?
Is “on the go” or often acts as if “driven by a motor”?
Interrupts or intrudes on others (for example, butts into conversations or games) ?
Please list anything you wish to add which the questionnaire did not address.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
To the best of my knowledge, I have answered the complete questionnaire.
________________________________
Signature
Reviewed form with the patient in its entirety.
______________________________
Joseph J. Callanan, M.D.
________________________________
Neetu Talreja, M.D.
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