Aair Allergy/asthma Patient Medical History
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Appt Time:_______________
AAIR ALLERGY/ASTHMA PATIENT MEDICAL HISTORY
Doctor:
Last Name:_________________ First:_____________ MI____ Date:__________ Date of Birth:__________ Age:_____ Sex:___
Address:____________________________________________________________________ Phone:_______________________
Primary doctor_____________________________ Referred by:______________________
Type of Insurance:______________
Other doctors seen and specialty: _______________________________________________________________________________
Other Family members seen by AAIR:_____________________________________________ doctor seen:____________________
Parent’s names (if minor) ___________________________________________ Person filling out form: ____________________
Welcome to our medical practice. Please complete this questionnaire completely prior to our visit. THANK YOU!!
I. DESCRIBE YOUR REASON(S) FOR THIS VISIT/CONCERNS: ______________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
II. SYMPTOMS: Please check all that apply.
NOSE/SINUSES: Age of onset of nasal symptoms ______________
1. Are nasal symptoms
Progressively worsening
Persisting
Getting better
___________________________________
2. Symptoms: Nasal blockage Nasal congestion Sneezing Sniffling
Itchy nose
Runny nose
Loss of smell
loss of taste
Nasal speech
hoarse voice
Snoring
awakening with mucus in throat
3. Color of nasal drainage
Clear
White
Yellow Green
Nose bleeds how often?__________________________
4. Post-nasal drainage/drip - Constant Periodic Occasional
Never When lying down
5. Clearing of throat -
Constant
Frequent
Occasional
6. Headaches/pressure N Y Where? Around/behind eyes forehead face/cheeks behind head/neck how often?___________
Have you been diagnosed with migraine headaches?
N Y triggers_______________________ what helps?_______________
7. Have you been diagnosed with sinus infections requiring antibiotics?
N
Y # of infections per year___________________
date of last infection___________ How treated (with what antibiotic/how many days) _______________________________
Do symptoms completely clear with antibiotics?
Y N minimal improvement
Temporary complete improvement
8. Have you ever had:
Broken nose
Deviated nasal septum
Sinus surgery
Nasal surgery
Tonsils removed
Adenoids removed
Nasal polyps
Details (&date) ________________________________________________________
Sinus Xray/CT? where_________________________ results________________________________________________
9. Are Nasal symptoms - All year
Spring
Summer
Fall
Winter
Which is worst? ____________________________
LUNGS: Age of onset of earliest lung/chest symptoms ______________
1. Symptoms: Cough Difficulty breathing Shortness of breath Chest tightness Wheezing Chest pain
2. Are symptoms worse
getting air in
getting air out
Both breathing in and out
when lying down
3. Do you have chest symptom with:
exercise/activity with all/most infections At Night
weather change
with anxiety
Outdoors in pollen season
Indoors
cold air
at work Other___________________
4. Do colds/infections settle in your chest?
All
Most
Some
Never
Do infections tend to linger in chest for extended period?
N Y how long?_________________________
5. Ever diagnosed with: Bronchitis?
N
Y how many per year?_____________
Pneumonia?
N
Y how many overall?______________ by Chest Xray? Y N
6. Do lung symptoms occur -
All year round
Spring
Summer
Fall
Winter
Which is worst? _____________
7. How many attacks of difficulty breathing in last one year? _____________ how long do they last?_________________
How long does each attack last?
Minutes to hours
Days
More than a week
Weeks
Months
8. How many times do you have symptoms per week on average? Daytime_________ Nighttime__________
9. Have you ever been given an inhaler or nebulizer?
Y N ___________________________
How many times do you use a rescue inhaler or nebulizer per week_________________
only with infections
Does it improve symptoms?
Y N
temporarily incompletely
10. How much time passes between attacks with no symptoms or need for inhalers?_____________________
11. Approximate number of school/work days missed per year due to chest symptoms:__________________
12. Number of Emergency room/Urgent Care visits for breathing __________ date of most recent _________________
Number of Hospitalizations for breathing __________ date of most recent _____________________
13. Ever been given oral steroids for breathing? (orapred, prednisone, medrol, ect.)
N
Y which one__________________
# of times last yr___________
# of times lifetime______________
date of most recent ___________________
14. When was your last Chest X-ray? ____________
results______________________________________________________
15. Do you have
heartburn
frequent belching
Sour/brash taste in mouth
how often?______________________________
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