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Patientquestionnaire.pdf

ALLERGY, ASTHMA & SINUS CTR. P.C.
Board certified in Adult & Pediatric Allergy & Immunology Patient Questionnaire

Name of patient __________________________ sex • M • F Date of birth ___________ Date seen ___________
* What is bothering you the most ? • Nose • sinus • eyes • lungs • Skin • other ________________________
* How long you have been having the problem?
few days few weeks few months 1-2 yrs 2-4 yrs 5-10 yrs > 10 yrs
A. Nose/ Sinus / Throat symptoms
____nasal stuffiness / congestion
____bleeding from nose
___ Sinus infection (…….… times in the last 6 months. My last sinus infection requiring antibiotic was on…………….)
* Nasal Discharge (in the last 1-3 weeks)
• clear • white • off white • light yellow • deep yellow • green * Blow your nose ( in the last 1-3 weeks)
• hardly ever • few times • many times • very often
B. Eye symptoms
____ swelling of the eyes
____ Dark circles/ swelling under the eyes ____ Dry sensation ____ Watering __ Diagnosed to have glaucoma C. Ear Symptoms
____ popping
____ Ear infections/ fluid in ears (……… ear infection in last 6 months) * Which month (s) are symptoms worse? May June July August September October November * Severity of symptoms mild mild- moderate Sinus CT scan (done when?__________________________) • Sinus x-ray Saw an ENT doctor (when ……………….……………) * What has been done to treat the problem? Over the counter oral allergy or cough / cold medications (containing antihistamines) • oral decongestant like Sudafed, pseudoephiderine (no antihistamine) • allergy eye drops like naphacon, vasocon, Visine, artificial tears________________ nasal sprays : Afrin, Dristan, Four way, Equate etc
( when did you use them last ___________)
: salt water sprays like Ocean, Ayr
Zyrtec, Zytrec-D, Claritin, Clarinex, Claritin-D, Claritin D 24, Allegra, Allegra -180, allegra -D • Duratuss GP, Entex LA, Entex PSE, loratidine, Panaz, Guaituss, Duravent-DA, Allerx, Rynatan, Ryna 12-S _______________ • Eye drops: Acular Alocril Alrex, Alomide Alamast Crolom Emadine Livostin Patanol,, Zatidor
Beconase, Flonase, Nasacort, Nasacort-AQ, Rhinocort, Rhinocort Aqua, Nasonex, Nasarel, Vancenase, Astelin, Nasalcrom
Cortisone like prednisone, Medrol dose pack,
cortisone injection: Kenlog, Depomedrol, Aristocort
Allergy shots ( given every 1-3 weeks for months and years, given to help build up immunity)
Antibiotics amoxicillin
Augmentin Augmentin ES Avelox, Bactrim, Biaxin Cefzil Ceclor Cedax Ceftin cephalexin Cipro doxycycline Dynabac erythromycin Kephlex Levaquin Omnicef Septra Sulpha Suprax, Tequin Vantin Zithromax Sinus surgery (clean sinuses) (when? _______________________) • nose surgery: septoplasty, turbinnectomy, polypectomy (When ? ____________ )
D. chest symptoms ?
Yes (how long? ________________________) Shortness of breath • difficulty taking a deep breath phlegm (what is the color/ amount __________________________ ) * Are these chest symptoms worse summer / spring / fall jogging/ running./ sports Cough/ shortness of breath ( wake up every day Heartburn (every day 1-2 times/ week 1-2 times/month 3-5 times / month) Stuffy head Lung test (Pulmonary function test) methacholine challenge test Chest X-rays (when/where __________________ ) blood test sweat chloride test Chest CT bronchoscopy childhood asthma adult onset asthma emphysema /COPD Reactive airway disease bronchitis pneumonia panic attacks anxiety Sleep apnea __________________________________ A. antibiotics B. Cough medicines: Cardec-DM, Histussin HC, Histinex, Histex, Rondec, Tussinex, Phenargan with codeine, over the counter stuff • Albuterol inhaler, Albuterol nebulizer, Acuneb, Duoneb, Albuterol liquid, Ventolin, Proventil, Xopenex • Aerobid Azmacort Pulmicort MDI Pulmicort respules 0.25 mg 0.50 ug Flovent 44 /110 / 220 Advair 100 / 250 / 500 Vanceril Qvar 40 80 *do you have a spacer like Aerochamber, Inspirase for the above inhalers? Yes * Are you on any one of these in the last 2 wks No yes which ones _____________________________
E. Systemic: having
chills lack of energy don’t feel fresh on waking up feel more sleepy than others loss of appetite wt. Loss / Gain (how much have you gained/ lost in last 1 yr? ………….)
F
. Gastrointestinal
* Do you have heartburn / acid in the throat/ difficulty eating or drinking ? 1-2 times a month 1-2 times a week Daily GERD Hiatal hernia • irritable bowel Peptic ulcer Crohn's / ulcerative colitis * Have you undergone Barium swallow, upper GI, Upper endoscopy, 24 hr P.H. probe _________________ omiperazole, Prilosec , Prevacid , Aciphex , Protonix, Nexium Ranitidine, Zantac, Axid, Cimetidine, Tagamet, Pepcid ____ Tums, Malox,Other antacids sold over the counter ____________________________________________ Seen a cardiologist / had a cardiac work up done YES NO Diagnosed with coronary artery disease, heart attack, angina, Atrial fib, CHF, mitral valve prolapse had EKG, ECHO, stress test , Treadmill, nuclear scan, angiogram coronary bypass, CABG, angioplasty, stent placed, pacemaker currently on medication for blood pressure, cholesterol, irregular heart rate………………. H. Urinary
hurtful urination, frequent urination, blood in urine, frequent urinary infection Diagnosed with prostate enlargement, prostate/ bladder / kidney cancer, kidney stones,
I. Joint related Swollen, painful joints, aches & pains in joints, stiffness
( none )
Diagnosed with rheumatoid, osteoarthritis, gout, fibromyalgia, herniated disk, _________________ low hemoglobin, excessive bruising, bleeding tendency _______________________________ ( none )
K. Endocrine under active or overactive thyroid, thyroid supplements (last blood test for thyroid?………………)
( none )
diagnosed with diabetes, eat excessively, feel more thirst insulin, oral diabetes medications (is diabetes well controlled?………………………)
L.
Psychiatric feel depressed, enjoy the usual thing of life ? Anxious
( none )
Diagnosed depression, anxiety, bipolar disorder, Panic attacks _________________________ On antidepressants, anxiety medications ___________________________________________
M. Reproductive
( none )
do you excessive menstrual blood loss? YES NO last menstrual period was on _______________ taking birth control pills for _______________ months /yrs Diagnosed with infertility, endometriosis, fibroid, PID, cervical /uterine cancer, testicular problems
O. Allergy
allergy / adverse reactions to foods, if yes which ones ________________________________ reaction after stung by bees, wasp, hornet, and yellow jacket difficulty breathing, hives all over __________________________________________ repeated infection / serious infections i.e. brain, blood, joints, lungs_______________________ Diagnosed with Migraine, chronic tension headache, stroke, epilepsy __________________ weakness of any body part, convulsions, difficulty walking, impaired memory, speech Did you have? CT scan of head, MRI brain, seen a neurologist (how long have you been having them? _____________ months / years) __ eye / behind the eye __ between eyes lasts for __ 1-3 hrs __ 4-12 hrs ___ 13-24 hrs ___1-3 days ___ more than 3 days very severe severe moderately severe mild varies Throbbing, pulsating pressure _ stabbing ________________ movement / bending the head before during or after menstrual period sleep deprivation / hunger aged cheese, red wine _ others ________________ • Tylenol Tylenol sinus, Tylenol allergy, allergy/sinus tablets • Motrin ibuprofen Aleve, Naprosyn, Excedrin, Midrin • Imitrex (tab, nasal spray, injection), Zomig Maxalt Amerge, Axert, Frova • Tylenol with codeine , darvocet, hydrocodone, Fiorinal , Fioricet Take these medicines daily few time/wk few times/month P. Skin problems?
All the time comes and goes lasts for _________ hours or days on some parts of body only ____________________ __ heat __Cold __Vibration __ Sun __pressure __exercise __water ____blood work ____seen a dermatologist ____seen regular doctor over the counter creams (name?………………………….……………….………………….) prescription steroid creams (name?………………………….……………………………….) Protopic 0.03% 0.1% Zytrec Atarax / hydroxyzine Zantac / ranitidine Benadryl,…………………………………………………. Medrol dose pack (packaged with decreasing number of tablets) Current list of medications:
1.

Allergies to medications: none
____________________________________________

Past history:

broke nose _______________________________ head injury sinus surgery / septoplasty / turbinnectomy / nasal polyps / sinus polyps removed Tonsillectomy (age………….) other surgery __________________________________________________ Admitted to hospital for_____________________________________ Diagnosed with childhood or adult onset asthma Diagnosed with - pneumonia (when was the last time? ______________ ) - blood clot in lung or leg - cancer (which part of body_______________________) - heart trouble
Less than 10 yrs old: Birth weight_________ lbs
Development appears to be age appropriate ____ yes ___ no Received pneumococcal vaccine (Prevnar) ____ yes ___ no Social history:
Never smoked smoked 1/2 1 2 packs/ day __ smoked for few months ____ few years __10-20 yrs ___ more than 20 yrs stopped smoking ____________ yrs ago Still smoke Have you tried stopping smoking YES NO tried going cold turkey, used nicotine patches, , nicotine nasal spray, nicotine inhaler, Zyban, wellbutrin
have children age (s) _________________________________________
Job / Travel History

student in school/ college _grade ________ work at current job for _______________ months / years
What is your job? ______________________________
Are symptoms worse at work YES
exposed to farming related products, toxic fumes, silica, asbestos, coal, now or in the past? YES when did you travel outside Iowa? ……………………………………. where did you go?……………………………………………………… Have you gone to Southern USA or outside USA ? YES NO
Environment
for
who smokes in the house?________________________________________ ___ cat ___ dog ___ bird ___ guinea pig ___ hamster ___ gerbils Cockroaches ___ cat ___ dog ___ horse ___ cattle ___ Hogs ___ others Yes / No
Family history
Allergies
Migraine
Immune-deficiency
Spouse's job_________________ Mother's job __________

Source: http://www.allergyasthmasinusctr.com/questionnaire/questionnaire.pdf

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