NAME:_____________________________________ DATE:_____________________

What is the major symptom or problem? Please explain in detail:

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Ocular/Nasal symptoms:

Nasal congestion? Circle YES or NO

Nasal discharge? Circle YES or NO if YES, what colour:_____________

Eye discharge? Circle YES or NO

Eye itching? Circle YES or NO

Eye redness? Circle YES or NO

Seasonal association? Circle YES or NO if YES, list months/seasons:_______

Chest symptoms:

Wheezing? Circle YES or NO

Coughing? Circle YES or NO

Shortness of breath? Circle YES or NO

If yes to any of the above, do symptoms occur with exertion (ie exercise)? Circle YES or NO

Home Environment

1. Do you live in a (circle appropriate): HOUSE APARTMENT CONDO Other: __________

2. How old is your place of dwelling in years: _______________
3. Do you have pets (circle appropriate): YES or NO If Yes, list pets: _______________
4. Do you have carpet at home ? Circle: YES or NO
5. If yes, is bedroom carpeted? Circle YES or NO
6. If applicable, list other carpeted areas:_______________________________________________
7. Do you have feathered pillows or comforters? YES or NO
8. How old is your mattress? ________________________________________________________
9. Is your home air conditioned? Circle YES or NO

Do you smoke? YES or NO If patient is a child, is he/she exposed to second-hand smoke? Y / N

If yes: __________________________ years, _________________________ packs per day

Do you drink alcoholic beverages? YES or NO

Please indicate frequency (number of drinks per day or week): _________________________________

Do you work? Circle YES/NO – If yes, list occupation and work location:___________________________
Are you in school? Circle YES/NO - If YES, list grade (also include daycare): ________________________

Do you have medication coverage: circle YES or NO – if yes, indicate(circle):PRIVATE/GOVERNMENT

Allergy History:

Do you have eczema? Circle YES or NO

History of food allergy? Circle YES or NO If yes, please list foods: _______________

History of drug allergy? Circle YES or NO Please list drug(s): ___________________

History of reaction to stinging insects? YES or NO

Have you had allergy shots previously? YES or NO If yes,

Past Medical History:

Please list any ongoing medical issues, including surgeries or specialists that you are seeing, or illnesses
that are being controlled with medications (for example, high blood pressure, diabetes, thyroid etc):

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Current Medications (include prescriptions, over-the-counter, herbal, vitamins):

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Please fill in the following table with checkmarks and/or written explanations within the boxes:

Environmental Food Drug Venom Asthma Eczema

Allergy Allergy Allergy allergy
Mom
Dad
Sibling
Other
__________
Does anyone in your family have a problem with their immune system? YES or NO

If yes, please describe: __________________________________________________________________

Please answer the following for patients under the age of 16:

How many weeks into pregnancy was the patient born?

Were there any problems throughout pregnancy?

Any complications with delivery?

Is the patient fully immunized?

Any problems with development?