Initial Visit Questionnaire Allergy-Immunology

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Patient Name*
Email*
Date of Birth*
MM slash DD slash YYYY
Who referred you for your allergy evaluation?*
What is the primary reason for your referral?*
Have you ever been diagnosed with allergic rhinitis (seasonal allergies)?*
- Yes
- No
If Yes, have you ever had skin or blood testing before?*
- Yes
- No
Have you ever been on allergy shots before?*
- Yes
- No
What triggers your symptoms? (check all that apply)*
- Pollens
- Grass
- Dust
- Wind
- Fumes
- Smoke
- Perfume
- Cats
- Dogs
- Vacuuming
- Mowing
- Exercising
- Temperature Changes
- Illness
- Cold Weather
- Other Animals
- Other
Other Animals*
Other*
Have you ever been diagnosed with asthma?*
- Yes
- No
Are you on any asthma medications?*
- Yes
- No
If yes, what medications are you taking?*
Have you ever been diagnosed with atopic dermatitis (eczema)?*
- Yes
- No
Have you ever been diagnosed with chronic hives (urticaria) or angioedema?*
- Yes
- No
Do you have a history of recurrent infections? (check all that apply)*
- Yes
- No
Do you have a history of recurrent infections? (options)*
- Ear Infections
- Pneumonia
- Sinus Infections
- Skin Infections
- Bone Infections
- Other
Other*
Have you ever been treated with antibiotics (more than 2 weeks) for sinusitis?*
- Yes
- No
Have you ever had an adverse reaction to foods?*
- Yes
- No
Which food?*
What happened?*

Have you ever had an adverse reaction to a bee, wasp, hornet, or fire ant?*
- Yes
- No
When?*
What happened?*
Are you allergic to any medications?*
- Yes
- No
Medication*
Reaction*
Medication
Reaction
What type of home do you live in? (check one)*
- Single family home
- Townhouse/Condo
- Apartment
- Barracks
Do you have the following in your home?*
- Carpet in bedroom
- Carpet in Living Area
- Drapes/Curtains
- Visible mold/mildew
- Window A/C unit
- Central A/C Heat
- Fire place
- HEPA Filters
- Humidifier
Do you have any pets (please indicate quantity) or other animal exposures*
- Yes
- No
Cats
Dogs
Birds
Goats
Horses
Sheep
Cows
Other
Do you have any exposures at home, work, hobbies, etc. that concern you (chemicals, fumes, vapors, etc)?*
- Yes
- No
Specify*
In the last 3 months have you had any of the following signs or symptoms?
Fever*
- Yes
- No
Nausea*
- Yes
- No
Chills*
- Yes
- No
Vomiting*
- Yes
- No
Unexpected weight loss*
- Yes
- No
Diarrhea*
- Yes
- No
Cough*
- Yes
- No
Skin Rash*
- Yes
- No
Wheezing*
- Yes
- No
Trouble with sense of smell*
- Yes
- No
Shortness of Breath*
- Yes
- No
Joint redness or swelling*
- Yes
- No
Heartburn*
- Yes
- No
Dizziness*
- Yes
- No
Abdominal Pain*
- Yes
- No
Headaches*
- Yes
- No
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Phone
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