ALLERGY AND ASTHMA ASSOCIATES
New Patient Questionnaire
Date of Appointment: _______________
Patient’s Name: ________________________________ Birth Date: ___________ Age: ______
Who is your primary care provider? __________________ Who referred you? _________________
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WHAT BRINGS YOU IN TODAY?
(Doctor’s notes:) _____________________________________________________________
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List any routine MEDICATIONS? _________________________________________________
Are you ALLERGIC to any medicines? _____________________________________________
Do you have any other HEALTH PROBLEMS?
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Have you had any SURGERIES on your tonsils, adenoids, ears, or sinuses? _______________________
Do you have any close FAMILY MEMBERS (e.g. parents, siblings) with allergies, asthma, or eczema?
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How long have you lived in the Pacific Northwest? __________ Have you lived elsewhere? ______________
Do you have any DOGS __________, CATS __________, or other PETS _____________ at home?
Have you ever SMOKED? ___________ Are you exposed to second-hand smoke? ________________
What do you do for a living (adults)? ________________________________________________
Do you have a favorite hobby or pastime? _____________________________________________
For Children:
Are your child’s VACCINES up to date? ___________________________________
Does your child attend DAYCARE? __________ If so, how many days/week?_________
Have you had a severe allergic reaction to a BEE STING? ____________________________________________
Have you experienced recurring HIVES or SWELLING? ____________________________________________
Have you experienced ANAPHYLAXIS (a whole-body reaction)? _____________________________________
Have you ever had ACID REFLUX (GERD) or taken antacid medicines? ________________________
Commons Professional Center ● 1200 112th Ave NE, C-210 ● Bellevue, WA 98004 ● (425) 454-2191 ● fax (425) 453-1270
Evergreen Professional Plaza, Suite F-260 ● 12911 120th Ave NE ● Kirkland, WA 98034 ● (425) 899-1458
ALLERGY AND ASTHMA ASSOCIATES
New Patient Questionnaire
If you have environmental allergy concerns:
Are your symptoms all year, certain seasons, or both? ___________________________________________
Symptoms triggered by (circle): cat/dog
dust
spring pollens
strong odors cigarette smoke
weather changes
other________
Have you ever had allergy testing? ____________ Do you recall the results? ___________________
Have you tried antihistamine tablets? ______________ Prescription nasal sprays? ________________
Have you ever had allergy shots? __________________________________________________
For asthma or breathing problems:
Were you ever diagnosed with asthma? _____________________________ At what age? ______________
Have you ever taken a daily medicine for asthma? _______________________________________
Have you ever been to the ER or hospitalized for an asthma attack? ____________________________
Do you get a flu shot every fall? ___________________________________________________
For food allergy or sensitivity:
Do you suspect certain foods are causing reactions? ______________________________________
Have you tried avoiding certain foods? _______________________________________________
Have you had food allergy tests (skin or blood tests)? ______________________________________
For hives (“welts”) or swelling:
Have you had hives, swelling, or both? _______________ For how long? _____________________
Have your hives ever been painful or left bruises? _______________________________________
Do you suspect a trigger? _________________ Have you tried any medicines yet?________________
Review of Systems: (Circle any symptoms you have experienced recently)
( □ check here if none apply)
General:
fever or sweats
fatigue
frequent or chronic infections
Nose/Eyes:
nasal congestion
runny nose
post-nasal drip
itchy/watery eyes
snoring
mouth breathing
Breathing:
cough
wheeze
short of breath
Skin:
hives or welts
swelling
itchy, dry skin (eczema)
GI:
nausea or vomiting
diarrhea
constipation
heartburn
acid taste
painful swallowing
Blood:
bruise or bleed easily blood clots
swollen lymph nodes
Neurologic:
(migraine) headaches dizziness
numbness or tingling
Heart:
chest pain
passing out
swollen extremities
Muscle/Joint:
joint pains
joint swelling muscle aches
Endocrine:
hair loss
thirsty often
feel too warm or too cool
Urinary:
urinary incontinence
frequent or painful urination
Psych:
feel anxious or sad
can’t fall asleep or stay asleep
Thank you for your responses!
MD initials ________
Commons Professional Center ● 1200 112th Ave NE, C-210 ● Bellevue, WA 98004 ● (425) 454-2191 ● fax (425) 453-1270
Evergreen Professional Plaza, Suite F-260 ● 12911 120th Ave NE ● Kirkland, WA 98034 ● (425) 899-1458