ALLERGY QUESTIONNAIRE
NAME
___ Date of birth: __________________
ADDRESS
___________________________________________________________________________
AGE
TELEPHONE
REFERRING DOCTOR’S NAME, ADDRESS AND TELEPHONE NUMBER:
_________________________________________________________________________
PRIMARY DOCTOR’S NAME, ADDRESS AND TELEPHONE
NUMBER:___________________________________________________________________
___________________________________________________________________________
NAME(S) OF ANY DOCTORS WHO WILL NEED TO KNOW THE RESULTS OF THIS
EVALUATION:_______________________________________________________________
___________________________________________________________________________
CURRENT MEDICATIONS (Include all non-prescription medicines, topical creams, eye drops,
nutritional supplements and nasal sprays):_________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
KNOWN DRUG ALLERGIES: __________________________________________________
Main reason(s) for visit:
[
[
[
[
[
[
] Nose, throat, eye or sinus symptoms
] Skin symptoms (hives, rashes)
] Asthma or breathing trouble
] Reaction to unknown substance
] Swelling
] Itching but no rash
[
[
[
[
[
[
] Medication allergies
] Insect sting allergy
] Suspected food allergy
] Advised due to abnormal lab test
] Recurrent infections
] Other, please specify ________________
SKIP ANY QUESTIONS OR SECTIONS THAT DO NOT APPLY
Please check all current respiratory symptoms: (skip section if none)
[
[
[
[
[
[
[
[
] Sneezing
[ ] Itching of the throat
[ ] Coughing
] Watery eyes
[ ] Frequent throat clearing
[ ] Nausea
] Runny nose
[ ] Shortness of breath
[ ] Wheezing
] Sinus infection
[ ] Swelling of the eyelids
[ ] Diarrhea
] Itching of the nose
[ ] Trouble sleeping
[ ] Blocked nose
] Itching of the ears
[ ] Get tired easily
[ ] Chest tightness
] Post nasal drip
[ ] Decreased sense of smell
] Other: please describe: ____________________________________________________
How long have you had these symptoms? (e.g., weeks, months, years) _________________
___________________________________________________________________________
When do the symptoms seem worse?
[ ] Mornings
[ ] Daytime when inside
[ ] Evenings
[ ] After meals
[ ] Middle of the night
[ ] At work or school
[ ] With exercise
[ ] When outside
In what season(s) are your symptoms worse?
[ ] All year round
[ ] Spring
[
[ ] Winter
] Summer
[
[
[
] On a dry windy day
] during rainy or damp weather
] When travelling
[
] Fall
Have you ever had allergy tests? [
] no
[
] yes
(if yes, when?) ________________
Have you ever had allergy shots? [
] no
[
] yes
(if yes, when?) ________________
Home Environment
How long have you lived at your current residence? _________________________________
Has your residence ever had water or flood damage? [
Does your house have:
[ ] Central air conditioning
[ ] Window A/C units
[ ] Attic fan
Does your bedroom have:
[ ] Carpeting
[
[ ] Potted plants
[
[ ] Stuffed animals
[
[
] A basement
] Gas heat
] Ceiling fan
] Bunk beds
] yes
[
] no
[
[
] Electric heat
] Electrostatic air filter
[
[
] Plastic mattress cover
] Venetian (mini) blinds
Circle the type of pillow you sleep on:
Feather / Foam / Fiberfill (synthetic) / Unknown / Other; ________________________
Do you have a:
[ ] Cat
[ ] Hamster
[
[
Are the pets: [
] inside
] Bird
] Horse
[
[
[
] outside [
] Dog
[ ] Gerbil
] Other animals (if so, what?)____________
] both
Does being around animals aggravate your allergic symptoms?
[
] no
[
] yes
Social History
Do you smoke? [ ] YES [ ] NO. How much and for how long? ______________________
If no, did you smoke in the past? [ ] YES [ ] NO. When did you quit? __________________
Alcohol use: [ ] never [ ] occasional [ ] daily -- amount/day: ___________________
Drugs of abuse [ ] never [ ] former (year stopped: _____________ )[ ] current
If you are having skin symptoms: (skip section if not)
When did it start? _______________________________________________
Where on the body does it occur? __________________________________
What time of day is it worse?
[ ] Mornings
[ ] Daytime
[ ] Evenings
[ ] After meals
[ ] Middle of the night [ ] At work or school
Do any of the following produce hives or itching?
[
[
[
[
[
[
[
] Heat exposure
] Sunlight exposure
] Damp rooms
] Pressure, prolonged sitting
] Rubbing or scratching
] Nervousness
] Prolonged standing
[
[
[
[
[
[
[
Do you suspect medication as a cause? [
] Exercise
] Bathing or showering
] Menstrual periods
] Stress
] Tight clothes
] Cold exposure
] Other, please specify: ______________________
] Yes
[
] No
If so, what? _______________________________________
Do you suspect something coming in contact with the skin as a cause? [
] Yes [
] No
If so, what? _______________________________________________________________
Do you suspect food as a cause? [
] No [
] Yes If so, what do you suspect? _________
If you had an insect sting allergy (skip if none)
[ ] Did you go to the emergency room? [
] No [
] Yes Which hospital? ______________
[ ] When did this happen?
Briefly describe symptoms after the sting: _________________________________________
___________________________________________________________________________
If you had a food or medication reaction or reaction to unknown substance
When did this occur? _______________________________________________
What food or drug to you think caused it? _______________________________
Describe what happened: ___________________________________________
________________________________________________________________
Medical History
For children only:
Are immunizations up to date? [ ] Yes [ ] No
Has the child had any trouble with routine vaccinations? [ ] Yes [ ] No
Was the birth premature? [ ] Yes [ ] No;
If yes, what was gestational age? _________
Have developmental milestones been on schedule? [ ] Yes [ ] No
Is child in daycare? [ ] Yes [ ] No Number of days/week: ________________
For all patients: Please answer questions with respect to the patient
Number and ages of children: (if applicable) _______________________________________
Do you have a history of:
[ ] High blood pressure
[ ] Thyroid disorder
[ ] Arthritis
[ ] Liver disease
[ ] Mental or nervous disorder
[ ] Diabetes
[ ] Circulation problems
[ ] Anemia
[ ] Recurrent fevers
[
[
[
[
[
[
[
[
] Heart disease
] Seizures
] Glaucoma
] Kidney disease
] Esophageal reflux
] Elevated cholesterol
] Frequent infections
] Cancer
Have you had any of the following symptoms or infections within the past year?
[ ] Strep throat
[ ] Swollen lymph nodes
[ ] Mononucleosis
[ ] Skin infection
[ ] Hepatitis, jaundice
[ ] Pneumonia
[ ] Yeast infection
[ ] Urinary tract infection
[ ] Infection of the gall bladder
[ ] tooth or gum infection
[ ] fungal infection of scalp, skin or nails
[ ] Blurry vision
[ ] Bronchitis
[ ] Sinus infection
If you are having frequent infections, please list what types and how often: ___________
_______________________________________________________________________
List any surgery you have had and include approximate dates? _____________________
________________________________________________________________________
List any previous hospitalizations with reason: ___________________________________
________________________________________________________________________
Have you had a tuberculosis (TB) skin test in the past 2 years? [
] Yes [
] No
Result: ________________
Family History
Mother [
] Living
[
] Deceased; Cause of death _____________________________
Father [
] Living
[
] Deceased; Cause of death _____________________________
Do any of these members of your family have allergies and/ or asthma?
[ ] Mother
[ ] Grandparent(s)
[ ] Brother(s)
[ ] Father
[ ] Aunt(s) or Uncle(s)
[ ] Sister(s)
Occupation:
Hobbies:
Any unusual exposures? (chemical, insecticides, paint, etc.)
Is there anything else that you think might be important for the doctor to know? ____________
___________________________________________________________________________
I authorize Dr. Jesse P. McRae M.D. to give me reasonable and proper medical care by
today’s standards.
Signature