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101 Darling Avenue, Waycross GA  31501, 912-287-1297 


 

Allergy History Form


Allergy History Form

Patient Name

Date of Birth:

Yes No Don't Know
Any skin problem?
Hives
Eczema

Yes No Don't Know
Any ear problems?
Popping
Itching
Hearing loss
Fluid in ears
Infection/pain

Yes No Don't Know
Any trouble with throat?
Post nasal discharge
Itching in throat

Yes No Don't Know
Any trouble with eyes?
Redness
Itching
Tearing
Puffiness

Yes No Don't Know
Any Nose or sinus problem?
Clear drainage
Thick colored drainage
Nasal itching and rubbing
Constant stuffiness
Sniffles
Sneezing
Mouth breathing or snoring

Yes No Don't Know
Any trouble with chest?
Wheezing with colds
Wheezing when exposed to dust, pollen, etc.
Wheezing after exercise

Cough?
Yes No Don't Know

Yes No Don't Know
What kind?
Deep/productive
Dry
Constant
Day time
Night time

During what months are your symptoms present?
All months Spring Summer
Fall Winter

When did your condition begin?

Do you use any allergy medications?
Yes No Don't Know

If yes, what medication?

Does it help?

Do any of your blood relatives have allergies?
Yes No Don't Know

Yes No Don't Know
Are your symptoms mild?
Moderate
Severe
Present most of the time
Present part of the time
Present rarely
Interfering with your life

What triggers your symptoms or makes them worse?
Indoors Outdoors At home
At work Morning Afternoon
At night

Which of the following weather conditions triggers your symptoms or makes them worse?
Wet weather Dry weather
Windy day Hot day
Cold day Air conditioning

Which of the following triggers your symptoms or makes them worse?

Yes No Don't Know
Mowing lawn
Dusty environment
High air pollution
Animals
Smoke
Perfumes / cosmetics
Milk / milk products
Eggs
Wheat products
Nuts, beans, seeds
Chocolate
Fish
Meat
Fruit
Alcohol
Aspirin

Chemicals (list):

Does your home have
Carpet / rug
Wood / tile floor
Indoor plants
Mildew under sink, washer, refrigerator

Yes No
Smokers in your home?
Do you smoke?
Any pets at home?

If yes, list:


For more information e-mail us.
2004 Kandallu R. Ramesh, M.D., P.C.

Any information provided on this Web site should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment.


        
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