ASTHMA & ALLERGY SPECIALISTS, LLC
Name:______________________________
DOB:___________
Primary MD:____________Date:_________
Reason for today’s visit: Sick ______ Routine follow-up ______ Allergy testing ______ Extract refill ______
What is your main problem?_____________________________
Current Allergy Symptoms or Problems: (circle all that apply)
runny/stuffy nose
post-nasal drip
sneezing
itching of eyes, ears, nose, throat, or skin
sinus pain or pressure
discolored mucus
headache
ears pop or click
wheeze
cough
tight chest
short of breath
other:__________________________________
skin rash
medication allergy
food allergy
How often are symptoms present:
daily
______ days/wk
______ days / month
never
For Asthmatic Patients: Asthma Control Test (circle one answer per question)
1) On average, over the past 4 weeks...How much of the time did your asthma keep you from getting as much
done at work, school or at home?
Often
Seldom
Rarely
Never
2) How often have you had shortness of breath?
Often
Seldom
Rarely
Never
3) How often did your asthma wake you up at night? +4 nights / wk
2-3 nights / wk
once / wk
never
4) How often do you use your rescue inhaler (albuterol, Maxair...) or nebulizer medication (albuterol, Xopenex...)?
3 or more times / day
1-2 times / day
2-3 times / wk Less than 2 times / wk
5) How well would you rate your asthma control during the past 4 weeks? Not controlled at all
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
REVIEW OF SYSTEMS (circle all that apply)
Do you use tobacco?
Y
N
CONSTITUTIONAL:
fever
weight change
other:
NEUROLOGICAL:
headache
other:
EYES:
blurry vision
itching
other:
EARS NOSE THROAT: snoring
nasal drainage
post-nasal drip
ear pain/pressure
other:
PULMONARY:
wheeze
cough
SOB
other:
CARDIOVASCULAR: high blood pressure
irregular heart beat
chest pain
other:
GASTROINTESTINAL: vomiting
diarrhea
constipation
indigestion
other:
GENITO-URINARY:
difficulty urinating
prostate (men) or menstrual problems (women) other:
ENDOCRINE:
thyroid problem
diabetes
other:
HEME/ONCOLOGY: cancer (please explain)_________________________________________ other:
JOINTS/RHEUMAT:
arthritis
joint swelling
joint pain
other:
SKIN:
rash
hives
eczema
itching
other:
PSYCHOLOGICAL:
anxiety
depression
ADD/ADHD
other:
Are you pregnant? Y N If “yes” what is your “due date”? _________________
PLEASE LIST ALL OF YOUR CURRENT MEDICATIONS AND DOSAGE (please include medication prescribed by all of
your doctors and any over-the-counter products
Drug Name
Drug Strength
How often do you take it?
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
______________________________ _____________________________ ____________________________
Nurse Init:___________
Rev 06/2012
Form 47
Downloaded from internet