Southwest Allergy and Asthma Associates

Joe Venzor, M.D.

Allergy Questionnaire

Date:___________ Referring Doctor:____________Referring Patient: ______________

Last Name:__________________First Name:________________Birthdate:_________

Male/Female. Length of Time in West Texas:________________

Phone (Home):__________Phone (Work):__________

MAIN SYMPTOM THAT AFFECTS YOU: ____________________________________

Date that your symptoms began:____________________________________________

ALLERGIC SYMPTOMS (check all that apply)

Nasal:□ Congestion □ Stuffiness

□ Clear runny nose □ Discolored mucus □ Sneezing

□ Itching □ Rubbing

Sinus:□ Headache □ Snoring

□ Loss of Smell □ Bloody nose

□ Bad Breath □ Sinusitis

□ Fever □ Chills
Throat:□ Hoarseness □ Postnasal drainage

□ Throat clearing □ Sore throat

Eyes: □ Itching □ Watering

□ Redness □ Swelling

□ Blurry vision

Ears: □ Pain □ Popping

□ Infections □ Tubes in ears

When placed______
Skin: □ Rash □ Itching □ Eczema

□ Insect sting reaction

Lungs:□ Dry cough □ Productive cough □ Chronic cough

□ Pneumonia When?___________

□ Bronchitis When?___________

□ Bronchiolitis When?___________ □ Past chest X-ray

When?___________

Hospitalizations?_____________________________________________

□ Wheezing □ Shortness of breath □ Chest tightness

□ Nighttime symptoms □ Symptoms with infections □ Spacer use

□ Symptoms only at work □ Recent albuterol use

□ Missed school or work □ Symptoms with exercise

Do you use a peak flow meter? _______ Last reading_________

THESE SYMPTOMS OCCUR DURING:

□ Spring □ Summer □ Fall □ Winter

□ Morning □ Afternoon □ Evening □ Night

□ At home □ At work □ Indoors □ Outdoors

SYMPTOMS ARE MADE WORSE BY:

□ Colds □ Cutting grass □ Raking Leaves □ Dust

□ Cigarette smoke □ Perfume □ Strong Odors □ Detergent

□ Airconditioning □ Exercise □ Stress □ Animal exposure

PREVIOUS ALLERGY OR ASTHMA MEDICATIONS:

Claritin □ Used □ Helped □ Sleepy

Claritin-D □ Used □ Helped □ Sleepy

Allegra □ Used □ Helped □ Sleepy

Allegra-D □ Used □ Helped □ Sleepy

Zyrtec □ Used □ Helped □ Sleepy

Zyrtec-D □ Used □ Helped □ Sleepy

Astelin □ Used □ Helped □ Sleepy

Hydroxyzine □ Used □ Helped □ Sleepy

Nasacort AQ □ Used □ Helped □ Sleepy

Rhinocort AQ □ Used □ Helped □ Sleepy

Flonase □ Used □ Helped □ Sleepy

Nasonex □ Used □ Helped □ Sleepy

Nasarel □ Used □ Helped □ Sleepy

Azmacort □ Used □ Helped □ Sleepy

Aerobid □ Used □ Helped □ Sleepy

Flovent □ Used □ Helped □ Sleepy

Serevent □ Used □ Helped □ Sleepy

Advair □ Used □ Helped □ Sleepy

Intal □ Used □ Helped □ Sleepy

Pulmicort □ Used □ Helped □ Sleepy

Singulair □ Used □ Helped □ Sleepy

Theophylline □ Used □ Helped □ Sleepy

Prednisone □ Used □ Helped □ Sleepy

Cortisone shot□ Used □ Helped □ Sleepy

Do you take Vitamins? □ Do you take herbal medications? □

PAST ALLERGY HISTORY:

Past allergy testing? Where?________________ When?________________

Prior allergy shots? Where?_________________ When?_______________

Reactions?__________Did the shots help?:

□ Completely □ Moderate □ Not at all □

□ Nasal surgery? Please describe___________________________________

□ Broken nose? When?______________________________________

FOOD ALLERGY:

Are there any foods that cause your symptoms?____________________________

Do any foods cause itching of your mouth?

□ Fresh fruits □ Fresh vegetables □ Other________________

DRUG ALLERGIES: ________________________________________________

DO YOU HAVE THESE IN YOUR HOME:

MEDICAL HISTORY:

Medical problems:_____________________________________________________________

Surgeries:___________________________________________________________________

Hospitalizations:_______________________________________________________________

CURRENT MEDICATIONS: (Continue on back if necessary)

Medication Name: Dosage When used? When Started: Reason for use

____________________|_____________|_____________|_____________|____________________

FAMILY HISTORY: Allergies Asthma Hives Eczema Sinusitis

Mother □ □ □ □ □

Father □ □ □ □ □

Son □ □ □ □ □

Daughter □ □ □ □ □

Grandfather □ □ □ □ □

Grandmother □ □ □ □ □

SOCAL HISTORY:

Do you smoke?______How long?_________When did you quit?_______________

What is your occupation?_____________________________________________

Hobbies?_________________________________________________________

DO YOU HAVE ANY OF THESE SYMPTOMS:

□ Arthritis □ Belly pains

□ Constipation □ Dark urine

□ Dizziness □ Easy bruising

□ Fatigue □ Feeling cold all the time

□ Fever □ Heartburn

□ Jaundice □ Weight loss