Twochiros.com

Grogan's Park Chiropractic Center - 25144 Grogan's Park Dr
The Woodlands, TX 77380
281-367-5020 / Fax 281-466-1019
www.TwoChiros.com
ALLERGY QUESTIONNAIRE
Patient Name:
Address:
Date of Birth:
City, State, Zip:
Gender (circle one):
Primary Care Physician:
Referring Physician:
Although your history and symptoms are very important in our analysis of your condition, it is also important for
us that you understand:
• We do not treat symptoms or diseases.
• Allergy is not a disease, rather a condition.
• A symptom is an attempt by your body to tell you something.
• We will attempt to find the underlying cause.
• We do not use drugs in this program.
• There is no single “healthy” diet that will work for everyone.
• Just because food is considered “healthy”, does not mean it is “healthy” for you.
• Your diet consists of everything you eat, drink, rub on your skin, or inhale.
• Our procedures are safe and painless.
Briefly describe the reason for your visit and what you hope to accomplish: AGE WHEN SYMPTOMS WERE FIRST OBSERVED
Infant (Age 0-2)
DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST
BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?
HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?
PREVIOUS DIAGNOSIS OF ALLERGY
Yes and allergy shots helped
FAMILY MEMBERS WITH ALLERGIC SYMPTOMS
Mother
FREQUENCY & SEVERITY OF ALLERGY SYMPTOMS
Constant/Chronic with little change
Considerable interference with normal life SYMPTOMS ARE WORSE
With yard work, cut grass, leaves, hay or barns Tobacco smoke bothers me more than anything else SYMPTOMS ARE BETTER
ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURE
FOOD RELATED SYMPTOMS
The smell or odor of some foods increases symptoms Some foods cause swelling of the mouth or tongue Some foods cause upset stomach or vomiting Symptoms occur with restaurant salad bars or Asian foods Symptoms occur with any regularly eaten food Preservatives, additives or food coloring increase symptoms FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE
CHEMICALS THAT CAUSE SYMPTOMS
The smell of new fabrics or fabric store WHEN ARE YOUR SYMPTOMS WORSE
MEDICATIONS
Do you take any of the following medications on a regular basis?
Antihistamines (Benadryl, Actifed, Chlortrimeton, Tylenol Sinus, Tylenol Sleep, Dimetapp,Drixoral, Trimalin, Bronchodilators (Albuterol, Ventolin, Proventil, Serevent, or OTS’s such as Primatine Mist, etc) Steroid Inhalers (Asmacort, Flovent, Pulmicort, Beclovent, Aerobid, Advair, etc) Nasal Steroids (Beconase, Flonase, Nasacort, Rhinocort, etc) Medications that affect the immune system (Prednisone, Imuran, Methotrexate, Cellcept, Cyclosporine, Please list any medications that you are currently taking:
SMOKING
Do you presently smoke?
If yes, average number of cigarettes per day PREVIOUS ALLERGY EVALUTION
Have you ever seen an allergist? Yes No
Have you had allergy skin testing?
If yes, please list positive allergens (include any medications) Have you ever received allergy injections? WORK ENVIRONMENT
What is your occupation?
Are you exposed to chemicals or strong odors at work? ANY ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW?
ANYTHING ELSE YOU WOULD LIKE TO ASK?

Source: http://twochiros.com/clients/4934/documents/ALLERGY_QUESTIONNAIRE.pdf