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Drok.ca

1 2 7 8 T H E Q U E E N S W A Y , E T O B I C O K E , O N , M 8 Z 1 S 3
P H O N E 4 1 6 8 4 8 9 7 9 5 • F A X 4 1 6 5 2 1 7 2 1 6
I R E N E F U N G , M D , F R C P C
A L L E R G Y , A S T H M A A N D I M M U N O L O G Y
**Note: for skin prick testing to be done at the clinic visit, the patient must refrain from taking oral antihistamines for at least 3 days prior to their appointment (eg. Azelastine,
Cetirizine, Chlorpheniramine, Cyproheptadine, Desloratadine, Diphenhydramine, Doxepin,
Hydroxyzine, Imipramines, Ketotifen, Levocetirizine, Loratadine, Terfenadine, Tripelennamine)

Surgical Procedures

Are immunizations up to date? Yes
Penicillin/Amoxicillin Other Drugs: ______________________________ Food: ____________________________________ Latex Other: ____________________________________ Family member (eg. Mother, brother, etc)
Environmental allergies


Drug allergy


Food allergy

Patient lives with (Circle all that apply):
Mother Father
Spends time between parents’ homes Grandparents
___ Brothers ____ Sisters
____ Children
Others: _________________
Circle any cooling system in home:
Central air conditioning
Window air conditioning
Is there carpeting in the home?
If “Yes”, where is the carpeting? ________________________________
Environment (circle all that apply):
Babysitter’s home

In-home baby-sitter
Home with parent/family member
Preschool
Work; Occupation: _________________

General Health Review (Circle all that apply): Chest pain
Mucus in chest
Bronchitis
Shortness of breath
Cough that won’t go away
Cough, wheeze or shortness breath with exercise, emotional upset, or cold air

HEART & BLOOD PRESSURE

Abnormal or rapid heart rate
Heart murmur
High blood pressure

EYE, EAR, NOSE & THROAT
Eye:
Swelling
Blurry vision
Balance problems
Frequent ear infections
Tympanostomy tubes
Hearing loss
Recurrent fluid in ears
Runny nose
Stuffiness
Sinusitis
Mouth breathing
Post nasal drip
Throat clearing
Large tonsils or adenoids
Frequent sore throat
Tingling
Swelling
Inflamed
Oozing/infected
Prior eczema

DIGESTIVE SYSTEM

Failure to thrive
Poor appetite
Frequent spit-up
Heartburn
Choking/gagging
Vomiting
Diarrhea
Constipation
Abdominal pain

DEVELOPMENT

Global delays
Delayed speech
Delayer motor skills

MUSCULOSKELETAL

Swollen joints
Fractures
Joint pain
Recurrent fevers
Number of antibiotic course in the last year: __________

Source: http://www.drok.ca/docs/NewPatientQuestionnaire-Allergy.pdf

Microsoft word - esser imperial.doc

JoeMeich Ministero dell’Informazione Esser Imperial Caffè Letterario Editore Prefazione In onore della festa della Costituzione (27 Ottobre) viene pubblicata questa raccolta di pensieri, che rispondono ad una semplice domanda… “Cosa significa per te essere imperiale?”. Purtroppo la partecipazione è stata bassa, 9 cittadini… anzi patrioti hanno risposto al mio app

As appeared on intermat - march 6, 1999

As appeared on Intermat - March 6, 1999 Skin Disease in Wrestling by Rob Lawton ATC In recent years, skin disease in wrestling has finally received the attention it deserves. With the NCAA mandating skin inspections prior to each competition, the wrestling community was forced to address the issue. For many years it was a taboo subject, similar to "cutting weight". Many ignor

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