Allergy Assessment Form

Allergy Assessment Form

Name____________________________________ Age__________ Sex_______________ Date__________________

I. Chief Complaint: ___________________________________________________________________________________ II. Present Illness: _____________________________________________________________________________________ III. Collateral allergic symptoms:
Eyes: Pruritus________ Burning _______ Lacrimation_______ Swelling _______ Injection ______ Discharge ________
Ears: Pruritus _______ Fullness ______ _ Popping _______ Frequent infections ___________
Nose: Sneezing ______ Rhinorrhea______ Obstruction ________ Pruritus_______ Mouth-Breathing _______________ Purulent Discharge ______________
Throat: Soreness
_______ Postnasal Discharge __________________ Palatal Pruritus _________________ Mucus in the Morning ___________________
Chest: Cough __________ Pain _____________ Wheezing _____________ Sputum _________ Dyspnea __________ Color ___________ Rest ______________ Amount _________ Exertion ___________
Skin: Dermatitis___________ Eczema_____________ Urticaria ____________

IV. Family Allergies ____________________________________________________________________________________

V. Previous allergic treatment or testing __________________________________________________________________
Prior Skin Testing ___________________________________________________________________________________
Medications: Antihistamines Improved ___________________ Unimproved ___________________ Bronchodilators Improved ___________________ Unimproved ___________________ Nose drops Improved ___________________ Unimproved ___________________ Hyposensitization Improved ___________________ Unimproved ___________________ Duration ___________ Antigens _____________ Reactions _______________ Antibiotics Improved ___________________ Unimproved ___________________ Corticosteroids Improved ___________________ Unimproved ___________________

VI. Physical agents and Habits: __________________________________________________________________________
Bothered by:
Tobacco for _______ years Alcohol ________________ Air cond.__________________
Cigarettes ________ packs/day Heat __________________ Muggy weather __________________
Cigars ___________ per day Cold __________________ Weather changes _________________
Pipes ____________per day Perfumes ______________ Chemicals _______________________
Never smoked ___________ Paints _________________ Hair Spray _______________________
Bothered by smoke __________ Insecticides ____________ Newspaper ______________________ Cosmetics _____________ Latex____________________________

VII. When symptoms occur: _____________________________________________________________________________
Time and circumstances of 1st episode: _________________________________________________________________
Prior Health _______________________________________________________________________________________
Course of illness over decades: progressing _________________ regressing _________________
Time of year: _______________________________ Exact Dates: __________________________________ Perennial _______________ Seasonal _______________ Seasonally exacerbated __________________
Monthly variations (menses, occupation) _______________________________________________________________
Time of week (weekends vs. weekdays) _________________________________________________________________
Time of day or night_______________________________ After insect stings ______________________________ VIII. Where symptoms occur: _____________________________________________________________________________
Living where at onset: _______________________________________________________________________________
Living where since onset: ____________________________________________________________________________
Effect of vacation or major geographic change: ___________________________________________________________
Symptoms better indoors or outdoors: _________________________________________________________________
Effect of school or work: _____________________________________________________________________________
Effect of staying elsewhere nearby: ____________________________________________________________________
Effect of hospitalization: _____________________________________________________________________________
Effect of specific environments: _______________________________________________________________________
Do symptoms occur around: __________________________________________________________________________ old leaves ____________ hay _______________ lakeside___________ barns ___________ summer homes _________ damp basement ___________ dry attic _______________ lawn mowing _____________ animals _______________ others ____________________________________
Do symptoms occur after eating: cheese _________ mushrooms _________ beer _________ melons _________ bananas_________ fish _________ nuts _________ citrus fruits _________ other foods (list) _____________________________________________________________________________
Home: city _________ rural _________ house _________ age _________ apartment _________ basement _________ damp _________ dry _________ heating system _________ pets (how long) ___________ dog __________ cat ___________ others ___________________________
Bedroom: TYPE AGE Living room: TYPE AGE
Pillow ____________ ____________ Rug ____________
____________
Mattress ____________ ____________ Matting ____________ ____________
Blankets ____________ ____________ Furniture ____________ ____________
Quilts ____________ ____________
Furniture ____________ ____________
Anywhere in home symptoms are worse: _______________________________________________________________ IX. What does patient think makes symptoms worse? ________________________________________________________ X. Under what circumstances is patient free of symptoms? ___________________________________________________ XI. Summary and additional comments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Assessed by : ________________________________________________ Date: ________________________