Laser Allergy Relief Center
HEALTH HISTORY QUESTIONNAIRE
IF YOU NEED ANY ASSISTANCE COMPLETING THIS FORM, PLEASE ASK THE FRONT DESK
PATIENT INFORMATION:
Today’s Date:_________________ Date of Birth__________________
Name: ____________________________________________________________________________________________
Address_________________________________________ City_________________ Prov_____ Zip_______________
Home Phone: ___________________ Work Phone _____________________ Cell /Pager: __________________
Male
Female
Email address _________________________________
Marital Status:
Married
Single
Divorced
Separated
Other ___________________
Mother’s Name, if minor____________________________ Father’s Name, if minor______________________________
Name of Individual to contact in case of emergency: __________________________Phone: _______________________
Number of Children: ____ Ages: ____
Your Occupation: ___________________________________________________________________________________
Referred to this office by: Friend or Patient – Name? ____________________________________________________
Other___________________________________________________________________________
Briefly describe the reason for your visit and what you hope to accomplish: _________________________________
__________________________________________________________________________________________
_________________________________________________________________________________________________.
What type of care are you looking for?
ARE YOU PREGNANT?
 Temporary Relief
NO
 Maximum Recovery
YES
Please List Possible Foods that Cause Symptoms ________________________________________________________
_________________________________________________________________________________________________.
Please List What Animals Cause Symptoms. ___________________________________________________________
_________________________________________________________________________________________________.
ARE YOU ALLERGIC TO ANY MEDICATIONS? NO YES / PLEASE LIST MEDICATIONS AND REACTIONS:
MEDICATION
REACTION
______________________________________________ / __________________________________________________
______________________________________________ / __________________________________________________
______________________________________________ / __________________________________________________
 more?… PLEASE LIST ADDITIONAL MEDICATION ALLERGIES ON THE BACK OF THIS PAGE.
Updated 1/27/2012
ARE YOU CURRENTLY TAKING ANY MEDICATIONS? NO YES / PLEASE LIST: 1.) ________________
2.) _____________________________ 3.) _____________________________ 4.) _______________________________
5.) _____________________________ 6.) _____________________________ 7.) _______________________________
 more?… PLEASE LIST ADDITIONAL MEDICATIONS, YOU ARE CURRENTLY TAKING, ON BACK OF THIS PAGE.
THESE PROBLEMS ARE:  RAPIDLY IMPROVING  SLOWLY IMPROVING  GRADUALLY WORSENING
 FLUCTUATES BUT GETTING BETTER
 REMAINS THE SAME
 RAPIDLY WORSENING
SYMPTOMS ARE WORSE IN THE
 Morning
 Afternoon
 Evening
SYMPTOMS/COMPLAINTS: COME & GO
ARE CONSTANT
AGE WHEN SYMPTOMS STARTED
 Infant (Age 0-3)
 Adolescent (Age 13-18)
 Adult (Age 26-40)
 Child (Age 4-12)
 Adult (Age 19-25)
 Adult (Age 41+)
NAME AND CITY/STATE OF DOCTORS/HEALTH CARE PROVIDERS PREVIOUSLY SEEN FOR
PRESENT CONDITION(S): _________________________________________________________________________
__________________________________________________________________________________________________
IMPORTANT INFORMATION FOR ALLERGY PATIENTS
● An Allergy is NOT a disease. It is nothing more than your body reacting inappropriately to what should be a
harmless substance, consequently activating the body’s natural defense mechanism in the form of symptoms.
● A symptom is an attempt by your body to tell you that something is wrong.
● We will be treating the root cause of your inflammation / allergy.
● We do not use medications in this program.
● Our procedures are safe, painless and effective for people of all ages.
PLEASE MARK WHICH SYMPTOMS or CONDITIONS APPLY:
SYMPTOMS ARE WORSE:
YES / NO
Outdoors, and better indoors
At nighttime
In the bedroom or when in bed
During windy weather
During wet or damp weather
When the weather changes
During known pollen seasons
In certain rooms or buildings
When exposed to tobacco smoke
Yard Work, cut grass, leaves, or hay
Sweeping or dusting
In Air conditioned rooms
Updated 1/27/2012
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FREQUENCY & SEVERITY OF SYMPTOMS:
YES / NO
Constant, chronic with little change
Present Most of the time
Present part of the time
Present rarely
Interferes with normal life
Slight interference with normal life
Considerable effect on normal life
Prevents most normal activities
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Blurred vision
Double vision
SYMPTOMS ARE BETTER:
Glaucoma
YES / NO
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After shower or bath
In an air conditioned room
Indoors
During or after physical activity
After taking medication
Right Now/In the Past/Never
Dry Coughing
Wet Coughing
Tightness Chest Pain
Asthma/Wheezing with Exercise
Asthma/Wheezing around Animals
Asthma/Wheezing during Pollen
Season
Asthma or Wheezing around Smoke
Shortness of Breath
Frequent Bronchitis
Recurring Pneumonia
Emphysema
COPD
Coughing Up Blood
Tuberculosis
YES / NO
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Recent weight gain
Recent Weight loss
Fatigue
Fever
Loss of appetite
Chills
Cancer of Any Kind
NEUROLOGICAL:
Right Now/In the Past/Never
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CHEST & RESPRITORY SYMPTOMS:
GENERAL:
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Lightheaded/Dizzy
Memory loss
Headaches
Migraines
Numbness
Weakness (Muscle)
Stroke
Tingling/Numbness
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CARDIOVASCULAR:
Right Now/In the Past/Never
Heart Attack
Swelling of Ankles
High Blood Pressure
Low Blood Pressure
Pain Down left Arm
Profuse Sweating
High Cholesterol
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NASAL SYMPTOMS:
Right Now/In the Past/Never
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Itching
Sneezing
Runny Nose – Clear discharge
Runny Nose – Cloudy discharge
Worse during pollen season
Post nasal drip
Nose Bleeds
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EYE SYMPTOMS:
Right Now/In the Past/Never
Itching
Excessive watering
Redness
Swelling
Worse during pollen season
Worse with animal exposure
Worse with smoke or chemical
exposure
Updated 1/27/2012
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THROAT & MOUTH SYMPTOMS:
Right Now/In the Past/Never
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Itching of the Throat and Mouth
Frequent Sore Throats
Frequent Laryngitis
Hoarseness
Frequent Tonsillitis
Mouth Sores
Swelling of Tongue or Mouth
Dental problems
EAR SYMPTOMS:
Right Now/In the Past/Never
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Itching
Hearing Loss
Blocking, Fullness, Popping
Frequent Ear Infections
Ear Tubes Inserted
Ringing in Ears
Ear pain
CHRONIC GASTROINTESTINAL SYMPTOMS
SKIN SYMPTOMS
Right Now/In the Past/Never
Right Now/In the Past/Never
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Nausea & Vomiting
Diarrhea
Gas, Heartburn
Cramps or Bloating
Abdominal Pain
Gall Bladder Problems
Liver Problems
Pain over Stomach
Ulcers
Colitis
Hiatal Hernia
Blood in Stool
GENITOURINARY:
Right Now/In the Past/Never
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Painful Urination
Blood in Urine
Frequent Urination
Kidney Infection
Kidney Stones
Incontinence
With allergy shot
Itching
Hives
Rashes
Sores
Eczema
Swelling
Rashes in the bends of
knees & elbows
Worse during pollen season
Worse with animal exposure
Skin symptoms are chronic
Bruise Easily
Discoloration
Changes in Moles
Scars
Skin symptoms are rare
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BONE & JOINT SYMPTOMS:
Right Now/In the Past/Never
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Updated 1/27/2012
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Arthritis
Rheumatoid Arthritis
Broken Bones
Osteoporosis
Gout
Scoliosis
Spinal Trauma
Bone & Joint
Redness or Swelling of Joints
Joint Stiffness, Limited Motion
Muscle Pain
Muscle Weakness
WHICH SYMPTOMS ARE THE MOST BOTHERSOME?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PLEASE EXPLAIN WHAT YOU HAVE DONE TO TRY TO CORRECT THE
SYMPTOMS
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HAVE ALL OF THESE TREATMENTS FAILED TO CORRECT YOUR PROBLEM?
YES
NO
HOW HAS THIS PROBLEM AFFECTED YOUR DAILY ACTIVITIES?
PLEASE CICLE YOUR LEVEL OF DISCOMFORT ON THE SCALE BELOW.
NO DISCOMFORT
1 2 3 4 5 6 7 8 9 10
WORST
I the undersigned confirm that the above information is correct to the best of my knowledge:
______________________________________________________ DATE:
Physician/Staff Signature
Updated 1/27/2012