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?
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Exercícios de revisão – Funções e isomeria Prof. Cristiano Rupp 1) Observe na ilustração a seguir estruturas de importantes substâncias de uso industrial. Em cada uma dessas substâncias, o número de átomos de carbono pode ser representado por x e o número de heteroátomos por y. O maior valor da razão x/y é encontrado na substância pertencente à seguinte função