Adult Allergy Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *Phone *SexMaleFemaleCHIEF COMPLAINT (reason for visit): PRIOR ALLERGY EVALUATION AND TREATMENT: Have you been previously evaluated for allergies?YesNoIf yes, complete this section Have you ever had an allergy skin test? YesNoIf yes, Date and Results?Have you ever had an allergy blood test? YesNoIf yes, Date and Results? Have you ever received immunotherapy (allergy shots)? YesNoIf yes, Date and For what allergies?FOOD REACTIONS: YesNoIf yes, complete this section Are you on any special diets? / Avoiding any foods? If yes, complete this section Food / Age / Avoided Symptoms / Still Avoiding?If you have multiple answers then number them.Do you have itching in your mouth after eating raw/fresh fruits or vegetables (i.e. bananas, melons, apples, peaches, pears, kiwi, citrus, tomato, potato), shellfish, peanut, or tree nuts? YesNoIf yes, please list specific food triggers and age of onset: ASTHMA HISTORY: YesNoIf yes, please list specific food triggers and age of onset: Age of onset / Frequency of attacks / Most recent exacerbationHave you ever needed any of the following for asthma? (Please answer with the most recent first.)Hospital admissions:Emergency room visits:ICU admissions:Intubations:Symptoms: Wheeze Cough Sputum Exercise Intolerance Chest Pain Shortness of breathNight time coughYesNoSeason worse inWinter Spring Summer FallALLERGY & ASTHMA TRIGGERS: (Please select choices, check “Yes” or “No”, and list symptoms)Grass exposure Yes No Symptoms Tree exposure Yes No Symptoms Damp areas with mold and mildewYes No SymptomsRaking leaves / Mowing lawn Yes No SymptomsSweeping / Dusting / VacuumingYes No SymptomsSmog / Air PollutionYes No SymptomsTemperature changes HotCold Not ApplicabeSymptomsTobacco smokeYesNoSymptoms ExerciseYesNoSymptoms Animals (cats, dogs, etc) YesNoSymptomsCoughing after drinking cold or hot water YesNoSymptoms Colds (Virals URI’s) YesNoSymptomsCleaning agents, fumes, perfumesYesNoSymptoms Others:INSECT ALLERGY: YesNo(If yes, complete this section)InsectUnknown HoneybeeYellow jacket WaspHornet Fire ant SymptomsLocal swelling Generalized swelling HivesPain WheezingShortness of breath Throat tightening Difficulty swallowing Loss of consciousnessLATEX ALLERGYYesNo(If yes, complete this section)Date / Source / Reaction MEDICATIONS Please list ALL medications, including any herbal or alternative medications, that you are currently taking (including dosage and frequency): Have you ever used the following medications: Nasal Sprays: Rhinocort Flonase Nasonex Nasacort Veramyst Astelin Afrin OtherIf yes, when, and at what dose & frequency? Inhalers: Proventil/Albuterol Xopenex Flovent Pulmicort Qvar Advair Inhaled cromolyn TheophyllineOtherIf yes, when, and at what dose & frequency? Last time used: MEDICATION / DRUG REACTIONSYesNo(If yes, complete this section) Date / Drug / Reaction / Taken SinceHISTORY OF REPEATED INFECTIONS: YesNo(If yes, complete this section) Type / Date / Antibiotic needed / Abnormal tests (i.e. Chest X-rays/ CT Scans/Blood tests) Types are as follow: 1. Ear Infections 2. Sinusitis 3. Pneumonia 4. Bronchitis 5. Meningitis 6. Dental Infections 7. Bladder/Kidney Infections 8. Skin Infections 9. Joint Infections 10. Gastrointestinal Infections OTHER MEDICAL/SURGICAL HISTORY: (Please answer all itemsA. List other medical illnesses: B. Any surgeries: C. Any ER visits/hospitalizations? For respiratory or allergic reactions? When?What treatment did you receive?D. For women, are your menstrual periods regular?YesNoNumber of days in typical cycle:IMMUNIZATIONS:A. Are your immunizations up to date?YesNoB. Which immunizations listed below have you received?Diphtheria Rubella Prevnar Tetanus Polio Pneumovax Measles HIB Meningococcal Mumps Hepatitis B Varicella C. Please list any adverse reactions to any immunizations: D. Did you receive the influenza (flu) shot during the most recent or current flu season?YesNoE. Do you plan to obtain the flu shot for the upcoming season?YesNoFAMILY HISTORY: (please complete)Mother’s health / ageFather’s health / age Brother(s)’ health / ageSister(s)’ health / ageDo any family members have a history of the following? List Relatives (indicate if outgrown and when)1. Asthma 2. Frequent Bronchitis 3. Frequent Pneumonia 4. Cystic fibrosis or Other Lung Disease 5. Hay fever/ Allergic rhinitis 6. Chronic Sinus problems 7. Hives/ Urticaria 8. Eczema 9. Migraines 10. Insect Allergy 11. Drug Allergy 12. Food Allergy 13. Celiac Disease 14. Immune disorders 15. Autoimmune disorders (Lupus, thyroid disease, Rheumatoid arthritis) 16. Inflammatory bowel disease 17. Early unexplained death in infancy 18. Frequent miscarriages ENVIRONMENTAL SURVEY:List the cities and states where you have lived from birth to present: City / State / Years / Effects on Symptoms (better, worse, no change) A. Approximately how old is your home? / How long have you lived there? B. Is your home a(n):single family home brownstone/townhouse apartment C. Does your home have:Central AC Window AC Wall Unit AC HVAC (heat & AC) wall unit Forced heatRadiator heat Gas heat Electric heat Humidifier Damp areas HEPA filter D. Do your windows have: curtains drapes shades blinds E. Does your bedroom have:wall-to-wall carpetinghardwood flooringarea rugsF. Where is your bedroom located? (floor or level of house) G. On your bed, are there:Stuffed toysDust mite proof coversFeather pillowsSynthetic pillowsMattressesWeekly washing of bed linensH. Do you have any pets (cats, dogs, birds, gerbils, hamsters, etc)? I. If you have pets, do they enter your child’sbedroom and/or bedJ. Are there any pet animals at school or work? Yes No K. Have you seen any pests in your home?Yes No L. Are you a smoker?Yes No M. Are there any other smokers in the home?Yes No N. What is your occupation? O. Other environmental or occupational exposures? Yes No P. Are your symptoms worse at school/work than at home? Q. Are there any other locations(s) where the symptoms are worse? R. How many days have you missed school/work because of asthma or allergies?15. COMMENTS: (Are there any other issues you would like to discuss at your visit?) WebsiteSubmit