Symptoms: Please mark which symptoms you have or have had in the past year.

ALLERGYCLINIC

Idaho

Allergy logo • 8.22.03

my allergy historyName__________________________________________________________

Today’s Date____________________

NASAL / SINUS n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Nasal congestion o o Headaches o o Snoring o oRelieved by decongestants o o Bad breath o o Nose bleeds o oNot relieved by decongestants o o Unpleasant taste o o Rubbing of nose o oItching o o Facial discomfort o o Loss of sense of smell o oSneezing o o Clear discharge o o Recurrent sinus infections o oRunny Nose o o Thick discharge o o Fatigue o oPost nasal drainage o o Mouth breathing o o Loss of sleep o o

EYES n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Itching o o Burning o o Dark circles o oWatery o o Puffy/Swollen o o Other: ___________________________

THROAT n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Itching o o Recurrent sore throat o o _________________________________

Loss of voice o o Chronic sore throat o o _________________________________

EARS n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Popping o o Dizzy o o _________________________________

Hearing loss o o Infections o o _________________________________

COUGH n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Continuous o o Barking o o With Sputum o oDay time o o Interferes with sleep o o Deep o oNight time o o Dry with no sputum o o Exercise makes worse o o

FOOD ALLERGIES n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Foods causing: Allergic reaction o o Hoarsenes o o Wheezing o oItching of mouth o o Change of voice o o Shortness of breath o oSwollen tongue o o Cough o o Loss of consciousness o oSwollen lips o o Hives o o Light headed o oItching of throat o o Nausea or vomiting o o Palpitations o oTightness of throat o o Diarrhea or cramps o o

Patients Initials__________PAGE 1 OF 7

FREQUENT INFECTIONS n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Chronic infections o o Recurrent Infections o o Skin Rashes o oIncomplete clearing o o Poor response to o o Growth failure o o of infection treatment Diarrhea o oONSETPlease check the specific symptoms and the season when it occurs/is worse. Leave blank if the specific symptom is not a problem.

Spring Summer Fall Winter Arising Morning Afternoon Evening Night

Wheeze o o o o o o o o oCough o o o o o o o o o

Shortness of breath/Chest tightness

o o o o o o o o o

Nasal stuffiness o o o o o o o o oNasal itching o o o o o o o o o

Sneezing o o o o o o o o oEye symptoms o o o o o o o o o

Throat symptoms o o o o o o o o oFatigue o o o o o o o o o

Animals n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Cats o o Dogs o o _________________________________

AGGRAVATING FACTORS: Please mark what makes your symptoms worse.

WEATHER n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Cold o o Humidity o o Temperature Changes o oHeat o o Air Conditioning o o Weather Changes o o

INFECTIONS n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Colds o o Sinus Infections o o _________________________________

IRRITANTS n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Dust o o Non-chemical odors o o Pollution o oPerfumes / scents o o Chemical fumes o o Smoke o oACTIVITIES n Yes n No (if no, go to the next section)

YES NO YES NO Other: ___________________________

Gardening o o Raking Leaves o o _________________________________

Mowing grass o o Exercising o o _________________________________

LOCATION n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Work o o Home o o _________________________________

School o o Farm o o _________________________________

Patients Initials__________PAGE 2 OF 7

MEDICATIONS n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Pain medications o o Blood Pressure (ACE inh.) o o Aspirin o oBeta blockers o o Eye drops o o Topical decongestants o o

OTHER n Yes n No (if no, go to the next section)YES NO YES NO Other: ___________________________

Foods o o Pregnancy o o _________________________________

Menstrual cycle o o Psychological factors o o _________________________________

TRAVEL n Yes n No (if no, go to the next section)YES NO YES NO YES NO

Salt air o o Mountains o o Urban areas o oHumidity o o Desert o o Rural areas o o

CURRENT ENVIRONMENT n Yes n No Type of home _________________________________________________________________________________

Age of home _________________________________________________________________________________

Time at current residence _________________________________________________________________________________

WORK ENVIRONMENT YES NO YES NO YES NO

Office o o Farm o o Daycare o oFactory o o School o o Other:_____________________________

Outdoors o o Health Care Facility o o ___________________________________

HEATING/COOLING YES NO YES NO YES NO

Electric o o Kerosene o o Air Conditioner o oGas o o Wood Stove o o Swamp Cooler o oOil o o Forced Aire o o HEPA Filter o oPropane o o Hot water o oAGRICULTURAL EXPOSURE

YES NO YES NO YES NO

Hay o o Alfalfa o o Corn o oWheat o o Potatoes o o Other_____________________________

Sugar beets o o Livestock o o __________________________________

COOKING YES NO YES NO YES NO

Gas o o Electric o o Propane o oFLOOR COVERINGS

YES NO YES NO YES NO

Wood o o Linoleum o o Carpeting, no pads o oTile o o Carpeting & Pads o o Rugs o o

Patients Initials__________PAGE 3 OF 7

AGGRAVATING FACTORS (continued): Please mark what makes your symptoms worse.

YOUR ENVIRONMENT:

WALL COVERINGSYES NO YES NO YES NO

Wall paper o o Paneling o o Sheetrock o oFabric wall “paper” o o Tapestries o o Plaster o o

WINDOW COVERINGSYES NO YES NO YES NO

Washable curtains/drapes o o Shades o o Vertical Blinds o oUnwashable curtains/drapes o o Horizontal blinds o o Other_____________________________

YOUR BEDROOM YES NO YES NO YES NO

Bare floors o o Curtains o o Down comforter o oBare floors with rugs o o Blinds o o Chenille bedspread o oCarpeting o o Stuffed animals o o Other_____________________________

FURNITURE YES NO YES NO YES NO

Wood o o Fabric upholstery o o House plants o oMetal o o Leather upholstery o oPlastic o o Vinyl upholstery o o

YOUR MATTRESS YES NO YES NO Other_____________________________

Innerspring o o Foam rubber o o __________________________________

Waterbed o o Futon o o _________________________________

YOUR PILLOWSYES NO YES NO Other____________________________

Feather or down o o Kapok o o _________________________________

Foam rubber o o Dacron or polyester o o _________________________________

PETSYES NO YES NO YES NO

Outdoor cat now o o Indoor cat in past o o Indoor dog now o oOutdoor cat in past o o Outdoor dog now o o Indoor dog in past o oIndoor cat now o o Outdoor dog in past o o Birds o oOther__________________________________________________________________________________________________________

OTHER FACTORS YES NO YES NO YES NO

2nd hand smoke o o Dampness o o Symptoms with hobbies o oMold or mildew o o Damp basement o o Latex/rubber exposure o oWater damage o o Window condensation o o

Patients Initials__________PAGE 4 OF 7

YOUR ENVIRONMENT (continued):

HAVE YOU BEEN ALLERGY TESTED? n Yes n No (if no, go to the next section)TYPE: YES NO YES NO YES NO

Do not recall o o Prick Test o o IDT o oScratch Test o o SET o o RAST o oOther o o

PREVIOUS TREATMENT:

ALLERGIC TO: YES NO YES NO YES NO

Dust o o Weeds o o Cats o oTrees o o Grass o o Dogs o oMolds o o Other_____________________________

PREVIOUS PHYICIANS TREATMENT n Yes n No (if no, go to the next section)YES NO Helpful Not Helpful

Medications o o o oimmunotherapy shots (weekly) o o o oReaction to shots? o o o o Explain_______________________________________

Steroid Injections (Depomedrol/Kenalog)

o o o o

SET o o o o

NASAL, ALLERGY, & ASTHMA MEDICATIONS Please mark all medications that you are currently or have previously taken.

ANTIBIOTICS PRESENT PAST PRESENT PAST PRESENT PAST

Amoxicillin o o Ceftin o o Omnicef o oAugmentin o o Doxycycline o o Suprax o oAvelox o o Dynabac o o Tequin o oBactim/Septra o o E-mycin o o Vantin o oBiaxin o o Levaquin o o Zithromax (Z-Pack) o oCeclor o o Lorabid o o Other___________ o o

ANTIHISTAMINE/DECONGESTANT COMBINATIONPRESENT PAST PRESENT PAST PRESENT PAST

Allegra D o o Comhist LA o o Semprex D o oClaritin D o o Rynatan o o Trinalin o o

ANTIHISTAMINESPRESENT PAST PRESENT PAST PRESENT PAST

Allegra o o Clarinex o o Periactin o oBenadryl o o Hydroxyzine o o Zyrtec o oClaritin o o Over the counter o o Other___________ o o

Patients Initials__________PAGE 5 OF 7

ASTHMAPRESENT PAST PRESENT PAST PRESENT PAST

Accolate o o Brethine o o Serevent o oAdvair o o Flovent o o Singulair o oAerobid o o Intal-Foradil o o Theophyline o oAlbuterol o o Maxair o o Vanceril o oAtrovent o o Prednisone o o Ventolin/Proventil o oAzmacort o o Pulmicort o o Other___________ o oBeclovent o o QVAR o o _________________

DECONGESTANTSPRESENT PAST PRESENT PAST PRESENT PAST

Entex o o Sudafed o o Other:___________ o o

EYEDROPSPRESENT PAST PRESENT PAST PRESENT PAST

Acular o o Crolom o o Patanol o oClaritin D o o Livostin o o Other:___________ o o

NASAL SPRAYPRESENT PAST PRESENT PAST PRESENT PAST

Astelin o o Flonase o o OTC nasal spray o oAtrovent nasal spray

o o Nasacort o o Rhinocort o o

Beconase o o Nasarel o o Vancenase o oCromolyn nasal spray

o o Nasonex o o Other:___________ o o

HEARTBURN MEDICATIONPRESENT PAST PRESENT PAST PRESENT PAST

Aciphex o o Prevacid o o Zantac o oAntacids (OTC) o o Prilosec o o Other:__________ o oAxid o o Protonix o o _________________ o oNexium o o Tagamet o o _________________ o o

COMPLICATIONS OF MEDICATIONSPRESENT PAST PRESENT PAST PRESENT PAST

Aspirin allergy o o Singing problems o o Speech problems o oFatigue o o Sleep apnea o o Other:__________ o oHearing Loss o o Nasal septal

perforationo o _________________ o o

Nasal polyps o o _________________ o o

Patients Initials__________PAGE 6 OF 7

Nasal Allergies

AsthmaSinus

ProblemsChronic Post Nasal

DrainageHives

Food Allergies

Drug Allergies

Father o o o o o o o

Mother o o o o o o o

Brother(s) o o o o o o o

Sister(s) o o o o o o o

Children o o o o o o o

Grandparents o o o o o o o

Aunt(s) o o o o o o o

Uncle(s) o o o o o o o

Cousin(s) o o o o o o o

Physician Comments________________________________________________________________

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Patient Signature__________________________________________________________________

Physician Signature________________________________________________________________

FAMILY HISTORY OF ALLERGY: To the best of your knowledge, mark which family members have the following history.

Patients Initials__________PAGE 7 OF 7