stcacupuncture.com - Allergy Questionnaire

Allergy Questionnaire
Patient Name:
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Gender:

MALEFEMALE
Home#:
Please enter a valid phone number.
Work#:
Please enter a valid phone number.
Primary Care Physician:
Referring Physician:
Although your history and symptoms are very important in our analysis of your condition, it is also important for us that you understand:
- We do not treat symptoms or diseases.
- Allergy is not a disease, rather a condition.
- A symptom is an attempt by your body to tell you something.
- We will attempt to find the underlying cause.
- We do not use drugs in this program.
- There is no single “healthy” diet that will work for everyone.
- Just because food is considered “healthy”, does not mean it is “healthy” for you.
- Your diet consists of everything you eat, drink, rub on your skin, or inhale.
- Our procedures are safe and painless.
Briefly describe the reason for your visit and what you hope to accomplish:
AGE WHEN SYMPTOMS WERE FIRST OBSERVED

Infant (Age 0-2)Child (Age 3-5)Child (Age 6-12)Adolescent (Age 13-18)Adult (Age 19-25)Adult (Age 26-40)Adult (Age 41 and over)
DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?
HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?
PREVIOUS DIAGNOSIS OF ALLERGY

Yes and allergy shots helpedYes but allergy shots did not helpYes and medication helpedYes but medication did not helpNone
FAMILY MEMBERS WITH ALLERGIC SYMPTOMS

MotherFatherBrother/SisterGrandparentsSon/DaughterSpouseNone
FREQUENCY & SEVERITY OF ALLERGY SYMPTOMS

Constant/Chronic with little changePresent most of the timePresent part of the timePresent rarelyPrevents some normal activitiesConsiderable interference with normal lifeSlight interference with normal lifeNo interference with normal life
SYMPTOMS ARE WORSE

Outdoors and better indoorsAt nighttimeIn the bedroom or when in bedDuring windy weatherDuring wet or damp weatherWhen the weather changes (geometric stress)During known pollen seasonsIn certain rooms or buildingsWhen exposed to tobacco smokeWith yard work, cut grass, leaves, hay or barnsWhen sweeping or dusting the houseIn areas with mold or mildewIn air conditioningIn fields or in the countryTobacco smoke bothers me more than anything else
SYMPTOMS ARE BETTER

After shower or bathIn air conditioningIndoorsDuring or after physical activityAfter taking antihistaminesWith allergy shots
What makes you feel better?
ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURE

DogsCatsRodents (mice, guinea pigs, etc.)Horses or CattleRabbitsBirds or FeathersBeesNoneOther
FOOD RELATED SYMPTOMS

Symptoms flare 5-60 minutes after mealsSome foods are craved or addictiveThe smell or odor of some foods increases symptomsSome foods cause nasal symptomsSome foods cause swelling of the mouth or tongueSome foods cause rashes or hivesSome foods cause upset stomach or vomitingSome foods cause diarrheaSymptoms occur with restaurant salad bars or Asian foodsSome foods cause headachesSymptoms occur with any regularly eaten foodSome foods cause asthmaPreservatives, additives or food coloring increase symptomsNo problem with foods
FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE

EggsMilkBeefCornWheatSoybeanPeanutPorkFishShellfishOrange or other citrusPotatoTomatoYeastChocolateCoffee or TeaNone
CHEMICALS THAT CAUSE SYMPTOMS

Insecticides & pesticidesPaints & household cleanersPerfumes & cosmeticsGasoline or automobiles exhaustStove or furnace emissionsThe smell of new fabrics or fabric storeChemicals in the workplaceLaundry detergentNewsprintNoneOther:
WHEN ARE YOUR SYMPTOMS WORSE

Year aroundJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
MEDICATIONS
Do you take any of the following medications on a regular basis?

Antihistamines (Benadryl, Actifed, Chlortrimeton, Tylenol Sinus, Tylenol Sleep, Dimetapp,Drixoral, Trimalin, Atarax, Claritin, Allegra, Zyrtec, etc)Bronchodilators (Albuterol, Ventolin, Proventil, Serevent, or OTS's such as Primatine Mist, etc)Steroid Inhalers (Asmacort, Flovent, Pulmicort, Beclovent, Aerobid, Advair, etc)Nasal Steroids (Beconase, Flonase, Nasacort, Rhinocort, etc)Medications that affect the immune system (Prednisone, Imuran, Methotrexate, Cellcept, Cyclosporine, Tacrolimus, etc)Chemotherapy
Please list any medications that you are currently taking:
SMOKING
Do you presently smoke?

YesNo
If yes, average number of cigarettes per day
Does anyone smoke in your home?

YesNo
PREVIOUS ALLERGY EVALUTION
Have you ever seen an allergist?

YesNo
Have you had allergy skin testing?

YesNo
Did you have any positive reaction?

YesNo
If yes, please list positive allergens (include any medications)
Have you ever received allergy injections?

YesNo
WORK ENVIRONMENT
What is your occupation?
Are you exposed to chemicals or strong odors at work?

YesNo
If yes, briefly explain
Are you symptoms worse while at work?

YesNo
If yes, briefly explain
ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW?
ANYTHING ELSE YOU WOULD LIKE TO ASK?
Should be Empty:

Allergy Questionnaire

MEDICATIONS

SMOKING

PREVIOUS ALLERGY EVALUTION

WORK ENVIRONMENT