| Rhinitis |
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Headaches |
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| Onset |
|
Onset |
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| Sneezing |
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Duration of episode |
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| Runny Nose |
|
Headaches (type) |
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| Discharge |
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Pressure |
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| Nasal Congestion |
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Throbbing |
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| Nose Bleeding |
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Location |
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| Loss of Smell |
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Frequency |
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| Nasal Polyps |
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Time Headache worse |
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| Post nasal Drainage |
|
|
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| Frequent sore Throats |
|
Associated Symptoms : |
|
| Cough |
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Nausea |
|
| Earaches |
|
Vomiting |
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| Ear Infections |
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Visual Disturbances |
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| Dizzy Spells |
|
Cause (s) |
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| Itchy eyes |
|
|
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| Watering |
|
|
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| Worst season |
|
|
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| Asthma |
|
Tension Fatigue SYNDROME |
|
| Onset |
|
Fatigue |
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| Cough |
|
Tension |
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| Sputum color |
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Excessive Sweating |
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| Wheeze |
|
Headaches |
|
| Tight chest |
|
Nausea |
|
| |
|
Vomiting |
|
| Attacks : |
|
Abdominal pain |
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| Night |
|
Diarrhea |
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| Day time |
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Constipation |
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| Work |
|
Bed wetting |
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| Frequency of attacks |
|
Pallor |
|
| |
|
Weight loss |
|
| Last attack |
|
Unexplained fever |
|
| Bronchitis |
|
Vague aches |
|
| Pneumonia |
|
Excessive school absences |
|
| Worst season |
|
Sleep-G-OK-Bad |
|
| Injections |
|
Dark ocular circles |
|
| Hospital Visit / Admissions : |
|
Per orbital edema |
|
| |
|
Cervical adenopathy |
|
| Days of missed work / School : |
|
|
|
| |
|
|
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| Quality of Life EX-G- OK-Bad |
|
|
|
| |
|
|
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| URTICARIA OR ANGIOEDMA |
|
DERMATITIS OR ECZEMA |
|
| Onset |
|
Onset |
|
| Duration of episodes |
|
Rash (describe) |
|
| Itching |
|
Itchy |
|
| Hives |
|
Scaley |
|
| Swelling |
|
Location |
|
| Location |
|
Infection |
|
| Ice-Sun-Food |
|
Cause (S) |
|
| |
|
|
|
| Other Symptoms : |
|
MEDICATION |
|
| Fever |
|
1. Allergy drug (s) |
|
| Joint pains |
|
Enumerate and indicate which one helps |
|
| Abdominal pain |
|
(a) Antihistamines / Decongestants : |
|
| Urinary infections |
|
(b) Asthma medication : |
|
| |
|
(c) Cortisone drugs : |
|
| |
|
(e) Others : |
|
| |
|
2. Others drugs |
|
| Insect Allergy |
|
PERCIPITATING FACTORS |
|
| When bitten |
|
(mark with x if symptoms are worsened or affected by) |
|
| Insect |
|
Weather change |
|
| Reaction (S) |
|
Rainy days |
|
| Treatment |
|
Foggy days |
|
| |
|
Changes in temperature |
|
| |
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Fumes (insecticides, chemicals) |
|
| |
|
Perfumes or cosmetics |
|
| |
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Cigarette smoke |
|
| |
|
House cleaning / dust |
|
| |
|
Infection |
|
| Allergy history |
|
PAST MEDICAL HISTORY |
|
| 1. Previous allergy test: |
|
Adults: |
|
| When |
|
Any chronic illness |
|
| By whom |
|
Treatment |
|
| Were allergy injections started |
|
Last complete (checkup-report) |
|
| How long were you on them |
|
Chest X-Ray (when-report) |
|
| Results |
|
Any other X-Ray |
|
| 2. Drug allergy (name drug and describe reactions) |
|
Hospitalizations (Date, diagnosis) |
|
| Food allergy (name food and describe symptoms) |
|
Surgeries: (Date, procedures) |
|
| Contact allergy (cosmetic, leather, Metals plants, etc.) |
|
Children: Pregnancy/Birth/Neonatal illness (describe if abnormal) |
|
| ENVIROMENTAL HISTORY |
|
Development History (teething/walking/talking) |
|
| How long have you lived in your present home |
|
Dietary history (breakfast/bottle fed, problems with any food, etc): |
|
| Location (city, farm, etc.) |
|
Any health problems (describe if any): |
|
| Air-conditioner |
|
Immunizations: |
|
| Pets: indoor Outdoor |
|
Special Information Patient wants to give |
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| Pillow type |
|
|
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| Mattress type |
|
|
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| Blanket type |
|
|
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| Carpet type |
|
|
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| Draperies type |
|
|
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| Indoor type |
|
|
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| Stuffed toys in bedrooms |
|
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| Smoker |
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| |
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