Allergy, Asthma, and Immunology
Dr. Robert Silge MD
Patient Name____________________________________________ Age__________ Date_____________
Address___________________________________________________________
Would you like a summary letter sent to your primary or referring doctor?
Yes No
Primary Doctor______________________________Address_____________________________________
Referring Doctor______________________________Address____________________________________
Email Address:_________________________________________________________________________
Do you have any family members who see Dr. Silge, if so who? __________________________________
Environmental Conditions:
Occupation___________________________ Hobbies______________________________
How long have you lived in Utah?__________________
Age of home_____________.
Years at present address____________.
Pets: n/a ___ cat___
dog___
bird___
other____________
Are pets outdoors? yes no
If in the house, are they in the bedroom? yes no
Heating system: gas___
electric___
wood___
coal___
oil___
Air conditioning: yes no
central___
swamp___
window___
Air filtering system: yes no
central___
room___
Humidifier: yes no
central___
room___
Fireplace: yes no
Water damage in home? yes no
Farm animals near home? yes no
What kind?_______________________________________
Neighborhood:
city___
rural suburbs___
country___
Review of General Health (circle)
General: chronic fever increased fatigue unintentional weight loss other________________
Eyes: vision changes itching
Ears, nose, throat: ear aches runny nose nose bleeds sore throat itchy throat
Lungs: shortness of breath chest tightness cough wheeze
Heart: chest pain abnormal heart beat fainting spells
Skin: new rash itching easy blistering
Endocrine: hot flashes cold or heat intolerance thirst
Blood/Lymph: swollen glands easy bruising anemia
Psychiatric: depression anxiety
Immune system: diagnosed immune deficiency
List any other health issues:______________________________________________________
Medication: Current medications not already listed above.
_____________________
_____________________
_____________________
_____________________
_____________________
_____________________
Family History: (please check)
Sisters/Brothers
Mother
Father
Children
Hay fever or other nasal allergy
_____________
______
_____
________
Asthma
_____________
______
_____
________
Eczema
_____________
______
_____
________
Hives
_____________
______
_____
________
Food allergy
_____________
______
_____
________
Family history of other diseases: (list)_________________________________________________
Environmental Conditions (cont.)
Smoking History: n/a___ smoker___ daily amount____ how many years____ others smoke at home___
Medical History: (circle all that apply)
heartburn
emphysema nasal polyps
diabetes
glaucoma
cataracts
cancer (list type)___________________
birth problems_____________________
heart disease
ulcers
urine retention
high blood pressure
other diseases______________________________
growth & development problems_______________
Hospitalization/Surgery/Emergency visits:
Reason__________________________________________________date_______________
Reason__________________________________________________date_______________
1) For those with HAY FEVER, CHRONIC NASAL CONGESTION, SEASONAL
ALLERGIES, or PET ALLERGY, please fill out this section:
Symptoms: (Circle all that apply)
Nose
Eyes
hay fever
itching
congestion
tearing
sneezing
swelling
running
redness
itching
styes
polyps mattering
bleeding
loss of smell
sinus infections
Ears
itching
blockage
infections
discharge
hearing loss
earaches
Throat
itching
hoarseness
voice loss
infections
postnasal drip
soreness
bad breath
dryness
Chest
asthma
cough
wheeze
mucus
tightness
short breath
pneumonia
congestion
bronchitis
When do these symptoms occur?
Spring Summer Fall Winter All year long
How long have you had these symptoms? _____ Years Worsening? yes no
Which of the following appear to cause these symptoms? (circle all that apply)
Pollen:
trees grass weeds
Animals:
cats dogs horses
other animals (list)________________________
Odors:
detergents
soaps
hair spray
paint fumes
perfumes
tobacco smoke
Other:
food
excitement
fatigue
medications (aspirin etc.)
inversions
cold air
exercise
infections (colds)
laughing
house dust
stress
weather changes
nighttime
other (list)___________________________________________________
Have allergy skin tests been done before? yes no Have allergy blood tests been done before? yes no
Doctor_________________________Date________________
Results_______________________________________Allergy shots? yes no from_____to_____
What medications have you taken for your hay fever/congestion symptoms? Please indicate response:
Medication
Helpful?
Medication
Helpful?
_______________________ yes no some
_______________________ yes no some
_______________________ yes no some
_______________________ yes no some
2) For those with ASTHMA/CHEST PROBLEMS:
How long have you had these symptoms? ______ Years Worsening? yes no
What triggers these symptoms?____________________________________________________
How often do you wake at night because of cough or wheezing?___________________________
How often do you use “rescue” medication (ie albuterol)? _______________. With exercise?____
How long ago did you last need prednisone for your asthma? ________________.
How long ago did you last need urgent care for your asthma? ________________.
Do you use a peak flow meter? yes no Personal best?______
Date of last chest x-ray_____________
Date of last sinus x-ray/CT scan_______________
What medications have you taken for your asthma symptoms? Please indicate response:
Medication
Helpful?
Medication
Helpful?
_______________________ yes no some
_______________________ yes no some
_______________________ yes no some
_______________________ yes no some
3) For those with ADVERSE REACTIONS TO FOOD:
List specific foods and describe reaction:
Food______________________Reaction:________________________________________________
When was first reaction___________________________. Most recent__________________________.
Food______________________Reaction:________________________________________________
When was first reaction___________________________. Most recent__________________________.
Food______________________Reaction:________________________________________________
When was first reaction___________________________. Most recent__________________________.
What treatment is usually needed? (circle all needed) Benadryl Zyrtec Claritin Epi-pen steroids
Do you have an Epi-pen/Epi-pen Jr.? yes no
4) For those with ECZEMA:
How old was the patient when this started?_____ Has it been continuous? intermittent?
What other symptoms are there with the eczema? (circle) itching sleep problems redness infections
What treatment is used? (circle) ointments creams baths wraps
What medications are used? topical steroids (list)____________________________________________
oral medications (list)__________________________________________________________________
5) For those with INSECT STING REACTION:
Insect___________________________ Reaction: ______________________________________
Insect___________________________ Reaction: ______________________________________
Other reaction:___________________________________________________________________
Date of first reaction_________. Most recent reaction__________.
Treatment: Benadryl Zyrtec Claritin Epi-pen
Do you have an Epi-pen/Epi-pen Jr.? yes no
ER
steroids
6) For those with HIVES/ITCHING/SWELLING:
General Features
Do you have hives or swelling or both? (circle)
Date of onset___________________ most recent episode_________________________
How often do you have the hives/itch:
Daily___
Weekly___ Monthly___
How often do you have the swelling:
Daily___
Weekly___ Monthly___
If intermittent, how long do they last? ____ minutes hours days weeks
Time of day when symptoms are most severe___________________________________
Parts of body affected by hives/itch_____________________________________________
Parts of body affected by swelling_______________________________________________
Do the hives: (circle)
itch
bruise
worsen with scratching
move daily
Do any of the following seem to be associated with the hives, itch or swelling? (circle all that apply)
exercise
soap
cosmetics
detergents
latex
stress
cough
wheezing
cold
heat
sunlight
pressure
vibration
animals
indoors
outdoors
nighttime
pregnancy
daytime
at home
at work
menstrual periods
tight clothing foods (list)__________________________________________________
Any other specific associations?___________________________________________________
Do you have any problems with the following? (circle all that apply)
sore throat
pneumonia
painful urination
sinus infections
yeast infections
fever
hepatitis
swollen glands
mononucleosis
skin infections
diarrhea
thyroid disease
tooth/gum infection
any autoimmune disease (ie lupus, arthritis)_____________________________________
Treatment
Please indicate the treatments that have been used in the past for your hives. Score your response to
each type of therapy:
0-No response
1-Slight response
2-Moderate response
3-Complete clearing
Antihistamine
______________
______________
Antibiotics
______________
Other
______________
Response
_______
_______
Response
_______
Response
_______
Steroids
______________
______________
Diet changes
______________
Response
_______
_______
Response
_______