Aair Allergy/asthma Patient Medical History Page 2
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4Name___________________________
EYES: Age of onset of earliest symptoms ______________
1. Symptoms:
Redness Itchy
Watery
Mattering
Puffiness around eyes
Darkening under/around eyes
2. Are symptoms - All year
Spring
Summer
Fall
Winter
Which is worst? ______________________
3. Are eye symptoms worse when nasal symptoms are bad? Yes
No
4. Do you wear contacts?
Yes
No Change how often?___________ Date of last eye exam ________________
EARS: Pain Itching Popping Plugging Decreased hearing
Infections , # per year_____ Ear tubes Y N date______
TRIGGERS: Which of the following exposures seem to worsen your NASAL, EYE, or LUNG symptoms?
Outdoors
Indoors
House work/Dusting
Lawn mowing
Yard work/Gardening
contact with grass Smoke
Exercise
Stress
Perfumes/Strong odors
Paint
Cosmetics
News print
Wet weather
Hot weather
Humidity
Cold air
Rapid temperature changes
air conditioning
Barns
Hay
Mold/Mildew Raking leaves
Damp places/basements
Cats Dogs
Other animals _______________
Alcoholic beverages
Aspirin/pain medications
Spicy foods
Worse at work
Vacation: where better?_________________________ Where worse?______________________________
food triggers_____________________
other triggers__________________________________________________________
HIVES/SWELLING: (if hives/swelling not an active concern, may skip this section)
Date of onset__________________
Currently active Yes
No
1. Symptoms with attack - Hives facial swelling Lip swelling Tongue swelling
Itching
Choking
Breathing trouble Abdominal pain
Nausea
Nasal symptoms Throat Swelling
2. Location - Face Trunk
Arms
Legs Hands
Feet
Other_______________
3. Frequency: Daily Weekly Monthly ___________________ How long does an attack last?______________
4. Worse with: Cold exposure
Heat
Exercise Sweating
Hot shower/bath
Swimming Outdoors
Stress
Pressure/prolonged sitting
Rubbing/scratching
friction/clothing contact
vibration
wind
animal exposure
5. Worse: Mornings
Evenings
Nighttime
After meals
with menstrual cycle
pregnancy
6. Any New foods/ingestions related to hives_________________________________________________________________
7. New/Recently added Medications________________________________________________________________________
8. New Herbal/nutritional Supplements______________________________________________________________________
9. Do you take over the counter pain medications? (Ibuprofen/Alleve)? How often?__________ Any relation to Hives? Y N
10. Any illnesses/infections prior to/during outbreak of hives? _____________________________________________________
11. Recent insect stings/bites No
Yes _______________________________
12. Latex exposure?
No
Yes where/what ____________________________
13. Ever Travel out of Country? where/when ____________________________
14. Ever have blood transfusion? Y N when___________________________
15. Do you have
ongoing sinus symptoms
dental problems/tooth pain __________________
16. New:
Soaps Lotions
Detergents Makeup
Sunscreen Fabric Softener
Other contacts_______________________
17. List all known or suspected things that may cause your hives_____________________________________________________
18. Description of hive History: _______________________________________________________________________________
______________________________________________________________________________________________________
19. What do you do/take to treat hives?__________________________________________________________________________
ECZEMA: Any current OR previous history of eczema?
No
Yes: Age of onset___________
Still present?
Yes No
1. Areas currently involved __________________________________________________________________________________
2. List all known or suspected triggers that aggravate eczema _______________________________________________________
3. Have you noticed any food correlation? N Y:_______________________________________________________________
4. When time of year is eczema worst? ________________________________ When better? ______________________
5. Moisturizing cream used: ________________________________________ How often?________________________
6. Other treatments used/tried: ________________________________________________________________________________
7. Bathing: frequency ______times per week
Approximate duration _______minutes
water temperature________________
FOOD ALLERGY: Do you suspect any foods cause adverse reaction/contribute to symptoms?
Yes
No
1. List all suspected foods and reactions: _______________________________________________________________________
_______________________________________________________________________________________________________
2. What reaction? Hives Swelling where_______________
breathing trouble
Throat tightness/itching
eczema
Rash
Abdominal Pain
gas/bloating
Vomitting
Headaches
Nasal symptoms
Other______________________________
3. How soon after ingestion do reactions occur? __________________________________________________________________
4. List all foods currently avoiding strictly________________________________ Previously tried to avoid _________________
5. Have you noticed improvement with avoidance? Which?_________________________________________________________
CONTACT ALLERGY: 1. Do you have skin rashes after contact with: Latex
Detergents Makeup Sunscreen Poison Ivy
Poison Oak/Sumac Exposures at work
Metals (Jewelry) type_______________
Other ___________________________
2. List names of any chemical, drug, ointments, etc., that produce skin rash ____________________________________________
3. List all reactions: ________________________________________________________________________________________
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