Amar J. Sharma, M.D., F.A.A.A.A.I.
Alena Kohler, M.S., PA-C
Allergy Associates ofLehigh Valley, P. C.
Allergy & Clinical Immunology
940N. New Street • Bethlehem, PA 18018 • Telephone(6l0)691-1133 • Fax(610)691-0581
Dear Patient,
Allergy evaluation consists of mainly three parts -History, Physical Examination, Skin Testing, sometimes Lab Work. The
most important part is History. That is why we ask you to please fill out the enclosed forms. I know it is lengthy, but it helps us
to evaluate your condition more thoroughly.
Patient Name
Date of Birth:
Your frrst visit with the allergist will include a detailed history of your problem, followed by a physical examination, and
perhaps allergy testing. During the history, you and the doctor will discuss:
• the chief problem which brings you to the allergist
• any non-allergy medical problems, past or present,
including any current non-allergy medications
• details of this chief problem, including its duration,
specific symptoms, and pattern
• your dietary, cigarette, and alcohol habits
• medications used for this problem, and their effect
• your family history of allergy and other medical problems
• factors, if any, which you recognize as worsening the
symptoms
• details of your home and other environmental exposures
• other allergy problems, past or present, in addition to the
current main problem
An accurate history is essential for proper diagnosis and treatment.
Please fill out this information before your visit, so that you can use your time with the doctor to your best advantage.
Part One - Health History
1. What chief problem(s) bring you to the allergist at this time?
2. If your problem is with the nose, ears or eyes, does it include:
0
0
0
0
0
0
sneezing
watery nasal discharge
discolored discharge
post-nasal drip
nasal itch
nasal blockage
D
0
0
0
0
0
D sinus infections needing
antibiotic( ___ per year)
0 ear infections needing
antibiotic( ___ per year)
0 loss of hearing
D itching of ears
loss of smell
mouth breathing
snoring
sinus pressure
nose bleeds
headache
D redness of eyes
0 itching of eyes
0 swelling of eyelids
0 tearing
0.________________
D.________________
3. If your problem is with the chest, does it include:
0
0
0
0
coughing
wheezing you can hear
wheezing heard by MD
tightness in chest
0
0
D
0
0 shortness of breath
0 awakening at night
0 chest pain
repeated episodes of bronchitis needing antibiotics (___ per year)
decreased exercise capacity
asthma attack(s) requiring emergency treatment
asthma attack(s) requiring overnight hospitalization
4. If your problem is with the skin, does it include:
0 hives
0 eczema
0 dryness
D redness
Ditching
1
5. If your problem is related to an insect sting, did you experience:
Cl swelling at the site of the sting only
LJ
U
0
hives over the entire body
swelling away from the site of the sting
dizziness or faintness
U loss of consciousness
wheezing
n fullness of throat or difficulty swallowing
I] nausea or vomiting ?
I]
6. Duration and pattern:
U symptoms have been present for _ _ weeks I months I years
0 spring
CJ fall
Ll year round at constant level
0 summer
0 winter
L] year round but worse during season(s) checked
7. Severity:
rJ mild
moderate
ll severe
I]
0
interfere with sleep
n interfere with physical exertion
IJ
interfere with school or work
8. Please list all prescription and non-prescription medications (including inhalers, nose
sprays, eye drops, and lotions) that have been used to treat these symptoms:
was it effective?
was it effective?
1~1
was it effective?
iI
was it effective?
I1
was it effective?
[! previous allergy testing?
when?
any side effects?_ _ _ __
any side effects?_ _ _ __
any side effects?_ _ _ __
any side effects? _ _ _ __
any side effects?_~--0 previous allergy injections?
ll
[I
when?_ _ __
9. Please mark those exposures that you know make you feel worse:
[J
exposure to house dust
cleaning house
[J
exposure to basements
I]
Cl moldy smells
0 raking leaves
0 playing in leaves
[I
n change in barometric pressure
[l
U change in temperature
IJ humidity
[J
wind
cold air
[J heat
0 rain
[J
U
exposure to compost
Ll night time
cats
IJ dogs
U horses
[J birds
D other animals· - - - - lJ
ll
morning
work
home
Ll school
[] other location- - - - U cigarette smoke
0
0
rJ
U
strong odors
perfumes
air pollution
chlorinated pool
1:1 meals
II
[J
recumbency
menstrual cycle
physical exertion
exercise
I -1 emotional stress
II laughter
ll alcohol
0 foods
-------
[J
cut grass
IJ plants
U gardening
[J
I]
f]
u----------___________
r!
------------
10. In addition to the main problem(s) discussed above, have you had other allergy
symptoms at any time?
0 infancy or early childhood_______________________
o food allergies
fuod _ _ _ _ _ _ _ __
fuod ___________
fuod ______________
food
[] medication ----------allergies
penicillin?________
how did you react?_ _ _ _ _ _ _ _ _ _ __
how did you react?_ _ _ _ _ _ _ _ _ _ __
how did you react?_ _ _ _ _ _ _ _ _ _ __
how did you react?_ _ _ _ _ _ _ _ _ _ __
how did you react?_ _ _ _ _ _ _ _ _ _ __
2
aspirin, Advil, etc.____ how did you r e a c t ? - - - : - - - - - - - - - - other________
how did you react?_ _ _ _ _ _ _ _ _ _ __
other________
how did you react?_ _ _ _ _ _ _ _ _ _ __
other________
how did you react?_ _ _ _ _ _ _ _ _ _ __
0 allergy to dye injected for X - r a y - - - - - - - - - - - - - - - - - - - 0 allergy to latex or r u b b e r - - - - - - - - - - - - - - - - - - - - - -
Patient's Name
---------------
n hives
~-~~~-----~~---------------------------­
[J impressive swelling of lips, tongue, or t h r o a t - - - - - - - - - - - - - - - -
IJ nasal drip or b l o c k a g e - - - : - - - - - - - - - - - - - - - - - - - - - snoring, mouth breathing or sleep a p n e a - - - - - - - - - - - - - - - - -
[1
n asthma, wheezing or shortness of breath_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
0
0
0
0
repeated ear infections requiring antibiotic ( __ per year)
repeated sinus infections requiring antibiotic ( __ per year)
repeated throat infections requiring antibiotic ( __ per year)
repeated bronchial infections requiring antibiotic ( __ per year)
0 insect sting allergy more than large swelling at site of s t i n g - - - - - - - - - - - 0 eczema
Cl poison ivy or other contact allergy
11. Please list any non-allergy medical problems that you now have, and the medicines
being used to treat them. Please include eye drops, vitamins, supplements and over
the counter medications you may take.
ll high blood pressure
0 heart disease
0 elevated cholesterol
0 ulcers
[J heartburn or reflux
lJ thyroid disease
D prostate or urinary
0 glaucoma
0 depression
D
ll
[l
ll
medication - - - - - - - - - - - - - - - - - - - - medication - - - - - - - - - - - - - - - - - - - - medication
medication
medication
medication
medication
medication
medication
medication
medication
medication
medication
12. Please list any previous medical problems, including hospitalizations and
surgery:
o________________________________________
o_________________________________________________________
o_______________________________________________________
o ____________________________________________________
13. If you are a woman, are you
D taking birth control pills?
0 pregnant?
Li planning to become pregnant?
if so, when _ _ __
Ll breast feeding?
14. Have you had recent X-rays?
0 chest
approximate date_ _ __
0 sinus x-ray
0 sinus CAT scan
approximate date_ _ __
approximate date._ _ __
result- - - - - - result- - - - - - result- - - - - - -
15. Please describe your social habits:
0 cigarettes
pack per day
D former smoker, quit _ _ __
D alcohol _ _drinks per__
0 former drinker, stopped_ _ __
0 coffee
cups per day
1:1 "recreational" drugs._ _ _ _ _ __
f] dietary habits
[I intake of milk and milk products._ _ _ _ _ __
Ll travel out of U S - - - - - - - - - - - - - - - - - - - - - - - - - - !] are you under any unusual emotional stress due to home, family or work? _ _ _ _ _ _ _ _ __
16. Please list allergies and major non-allergic illnesses in family members:
n patient's f a t h e r - - - - - - - - - - - - - - - - - - - - - - - - - - -
Ll patient's mother-~-----------------------[_]patient's brother(s)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
!J patient's sisters(s) - - - - - - - - - - - - - - - - - - - - - - - - - 0 patient's c h i l d r e n - - - - - - - - - - - - - - - - - - - - - - - - - 0 patient's g r a n d p a r e n t s - - - - - - - - - - - - - - - - - - - - - - - - 0 patient's cousins, aunts, u n c l e s - - - - - - - - - - - - - - - - - - - - - -
~ocial History!
Primary Residence for the patient is:
[ ]
[ ]
One Home
Split between homes
Current occupation is:
--------------------------Occupational exposures:
------------------------
Smoking: Y [ ] N [ ] If yes, years___ packs/day___
Use of Recreational Drugs
Smoked
Intranasal
Other
----
Drink Alcohol? Y [ ] N [ ]
Number of drinks per day___
Other relevant social factors:
---------------------
!Review of Systems: (check ifpresent)j
0
0
0
0
0
0
0
0
0
0
0
0
Fever
Weight loss
Skin problems besides eczema
Joint swelling or pain
Blood count problems (anemia, ect.)
Eye problems
Throat infections
Heart problems, high blood pressure or palpitation
Stomach upset
Urinary or bladder problems
Nerve or psychiatric problems
Hormone problems (such as hot flashes, etc.)
!Other Comments:!
Name of person filling out this history form (please print): _____________________
Relationship if not the p a t i e n t : - - - - - - - - - - - - - - - - - - - - - - - - - - -
Patient's Name
---------------------------Part Two--Environmental History
Type of home
Type of area
[I private house
0 condominium
D apartment in apt. building
D apartment in house
IJ dormitory
46
47
residential
IJ wooded
[J farmland
Durban
D near lake or pond
D near highway or factory
IJ
Humidification
Basement
48
none
de-humidifier
Ll room humidifier
[J central humidifier
ll finished
[1
D unfinished
[J none
IJ damp and musty
D dirt cellar
[J
Heating
Supplementary Heating
49
I] none
[J wood stove
IJ kerosene heater
0 fireplace
U baseboard hot water
D radiator hot water
0 forced hot air
0 electric baseboard
D wood stove
Cooling
Air cleaners
iJ none
50
none
: l central
i I room air cleaner, "HEPA"
r_l room air cleaner, not "HEPA"
ii
room air conditioning, including patient's room
room air conditioning, not in patient's room
l] central air conditioning
0 whole-house attic fan
0 window fans
r·J
[J
Stove
51
LJ electric
[J
gas, with pilot light
U gas, without pilot light
Bedroom floor
D wall-to-wall carpet over plywood sub-floor
0 wall-to-wall carpet over hardwood floor
D hardwood floor
[J hardwood floor with large area rug
Bed
52
hardwood floor with small area rug
0 tile
D linoleum
LJ
Mattress
0 standard bed
IJ standard innerspring
53
0 water bed
0 padded water bed
0 bunk bed, patient on top
[l bunk bed, patient on bottom
0 canopy bed
0 crib
Pillow
0 foam
[J
futon
0 waterbed
0 horsehair
0 encased in dust-proof cover
0 crib mattress
Blankets
dacron I polyester
LJ down I feathers
IJ foam
[J encased in dust-proof cover
[J none
[I
[l
U
0
[l
11
[I
Other items in bedroom
54
synthetic
cotton
electric
wool
down I feathers
comforter
Bedroom shared
none
0 few stuffed toys
0 many stuffed toys
0 upholstered chair
0 wall hangings
D curtains
[I pennants
LJ plants
55
0 no
[J
0
0
0
0
with one sibling
with two or more siblings
with spouse
with significant other
Cats
56
ll none
LJ one
Cl two
l.l three
U four or more
D run of house
i-1 sleep on patient's bed
II kept out of patient's bedroom
L I outside in warm weather
l I outside only
0 present for I year
0 present for 2 years
! ! present for 3 years
I I present for 4 years
I I present for 5 or more years
Dogs
57
0 none
D one
IJ two
U three
lJ four or more
run of house
0 sleep on patient's bed
fJ kept out of patient's bedroom
IJ outside in warm weather
IJ outside only
[J
0 present for 1 year
0 present for 2 years
il present for 3 years
r J present for 4 years
lJ present for 5 or more years
Other animals
0 none
0 bird
[I horse
58
0 cattle
0 _ _ _ __
D rabbit
D guinea pig
IJ hamster
D gerbil
0 mouse
Cl ferret
IJ ladybugs
!I mice
59
Hobbies
60
Ll _ _ _ __
Pests
[I
cockroaches
Secondary cigarette exposure
0 none
1:::1 father
[] father, but not indoors
0 mother
0 mother, but not indoors
0 gardening
0 woodworking
!] exercise
IJ sports
IJ music
0 dance
0 both parents
I]
I]
spouse or significant other
work
Chemical exposures
none
insecticides
fabric softeners
[1 NCR paper
IJ photocopiers
0
0
0
o _____
t_!
rj
-----------
Occupation
0
homemaker
0 student
0 office worker
0 factory worker
lJ teacher
61
0
executive
0 business owner
0 child
11 _ _ _ _ _ __
lPAST MEDICAL HISTORY!
Hospitilizations: Age or
Year
for ________________________
for
for __________________________
----------------------------
Surgeries:
for
for ---------------------------__________________________
for _____________________
Emergency Visits:
__ Times in past year
_ _ Times in past five years
Drug Allergies:
Symptoms:
_ _ _ _ _ _ _Caused_ _ _ _ _ _ _ _ _ _ _ __
_ _ _ _ _ _ _Caused_ _ _ _ _ _ _ _ _ _ _ __
- - - - - -Caused
Immunizations up to date for the age: Y[ ] N [ ]
Immunization Adverse Reactions:
_ _ _ _ _ _ _ _ Caused________________________
-----------------------
Other Chronic Health Conditions:
Age or
Year
Since
-----------------------Since
-------------------------Since-----------------------------Notes:
!Family Histol'Yl
Allergies Asthma Freq. coughing Freq. Infections
o
o
o
o
Father
Mother
0
0
0
0
Brother(s)
o
o
o
o
Sister(s)
0
o
o
o
Grandfather( s)
o
o
o
0
Grandmother(s)
O
O
o
o
Uncle(s)
0
0
0
0
Aunt(s)
0
0
0
0
Cousin(s)
0
0
O
0
Other chronic conditions such as cystic fibrosis, emphysema,
recurrent hives or swelling, lupus, rheumatoid arthritis, etc.;
Patient's Name:
--------------------------------9
~YMPTOMS GET WORSE OR IMPROVE!
Outdoors [ ]
Indoors [ ] At work or school [ ]
All day [ ] Night or morning [ ]
Patient's Name:
--------------------------------
~YMPTOMS ARE MADE WORSE BY:j
[
[
[
[
[
[
[
] Colds/Infection
[
] Cigarette smoke
[
] Mowing grass
[
] Raking leaves
[
] Perfumes or scents [
] Dusting or cleaning [
] Food
[
] Cats/Dogs
] Weather changes
] Windy days
] Damp areas
] Heat
] Cold
] Other
!ALL CURRENT MEDICINES number mg, tab, caps, or inhaler puff~
- - - - - - - - - - - - - - - - - - _ _ _ _ _ Times per day
- - - - - - - - - - - - - - - _ _ _ _ _ Timesperday
- - - - - - - - - - _ _ _ _ _ Timesperday
- - - - - - - - - - - - - - _ _ _ _ _ Times per day
- - - - - - - - - - - - - _ _ _ _ _ Times per day
!PREVIOUS ALLERGY OR ASTHMA MEDICA TIONS(INCL. OTC):j
- - - - - - - [ ] helped [ ] no help [ ] drowsy [ ] jittery
_ _ _ _ _ _ _ [ ] helped [ ] no help [ ] drowsy [ ] jittery
_ _ _ _ _ _ _ [ ] helped [ ] no help [ ] drowsy [ ] jittery
!CURRENT ENVIRONMENT (X IF PRESENT):!
Home/Apt
How old is the building?
Yes/No
Cats
DO
DO
Dogs
DO
Birds
DO
Other pets
0 0
Feather pillows
DO
Down comforter
0
0
Carpets or rugs
0
0
Air cleaner
DO
Cigarette smoke
Length of occupancy
Yrs
Baseboard Heat
Forced air heat
Air conditioning
Humidifier
Lots of houseplants
Damp baseball
Mold growth
Roaches
Improvements on trips
Yes/No
DO
DO
0 0
DO
DO
DO
DO
0 0
0 0
!PAST ALLERGY HISTORY: (Use space at right if needed~
Yes/No
Previous allergy testing? 0 0
If yes then answer the questions below:
Testing done by Dr.
in 19
Previous allergy shots DO
Still on allergy shots 0 0
Shots are received every __ week now
Allergy shots helped 0 0
Only minor reaction with the shots 0 0
If major reactions then explain:
DO YOU HAVE ALLERGIES?
DYes
D No
D Don't Know
What are you allergic to?
e
PATIENT QUESTIONNAIRE
DO YOUR BLOOD
RELATIVES HAVE ALLERGIES?
DYes
DNo
IJ Don't Know
CHECK ANY OF THE FOLLOWING MEDICAL
CONDITIONS YOU HAVE OR HAD.
D High Blood Pressure
D Heart Disease
D Stomach or Intestinal Disease
D Overactive Thyroid
D Underactive Thyroid
D Any Hormonal Difficulty
D Migraine Headache
D Frequent Headaches
D Asthma
D Sinus Disease
D Emphysema
D Nasal Polyps
D Bronchitis
D Broken Nose
0 Hay Fever
0 Nasal Surgery
D Hives
0 Deviated Septum
D Skin Disease
D Food Allergy
D Drug Allergy
What drugs?
D Other Conditions
CHECK SYMPTOMS YOU
USUALLY HAVE:
D Itching of Nose
D Stuffy Nose
D Nose Running
D Sneezing
D Post-nasal Drip
D Loss of Smell
D Eyes Itch
D Eyes Water
D Throat Itch
D Ear Infection
D Sore Throat
0 Cough
DWheeze
HOME:
D House
DApt.
DCity
0 Country
e
NAME
WHAT MEDICATION DO YOU
BY
TAKE DAILY OR FREQUENTLY?
DATE
D Aspirin
DVitamins
D Cortisone
D Ointments
D Laxatives
D Nose Drops
D Hormones
D Sedatives
D Birth Control Pills
D Other (list):
DO YOU USE MEDICATION
REGULARLY FOR NASAL
SYMPTOMS?
DYes D No
What is it?
NOTES
Does it help?
HEATING SYSTEM:
DNone
D Electricity
DOil
0 Don't Know
DGas
DOther
DCoal
METHOD OF HEAT DELIVERY:
D Hot Air Blower
D Radiators
D Electric Panels
D Don't Know
YOUR ENVIRONMENT:
AIR-CONDITIONING:
D Bedroom
DAtWork
D Central
DNone
ARE SYMPTOMS:
D Constant
D Erratic
0 Present Most of Time
D Present Part of Time
0 Present Rarely
DO YOU USE HUMIDIFIERS?
DYes
DNo
DSame
IN PAST
D Dog
DCat
DBird
D Rodent
DOther
Cigars
#~_/day
Years Smoked:
Stopped smoking in _ _
~--·~
ARE YOUR SYMPTOMS:
D Slight
0 Moderate
0 Severe
DO YOUR SYMPTOMS
INTERFERE WITH YOUR LIFE?
D Not at All
DA Little
0 Moderately
D Prevent Many Normal Activities
Other animals you
frequently contact:
AT PRESENT
D Dog
DCat
D Bird
D Rodent
DOther
DURING WHAT MONTHS DO YOU
USUALLY HAVE SYMPTOMS?
D All months
DOct.
D July
DJan. DApr.
D Nov.
DAug.
0 Feb. DMay
0 Sep.
0 Dec.
DMar. OJune
SMOKING HABITS:
Cigarettes #_/day
Pipe #_/day
MATIRESS:
0 Cotton
D Foam Rubber
D Horse Hair
D Feather
D Don't Know
DOther
ANIMALS IN HOME:
OCCUPATION:
Prominent materials used:
At work, are your symptoms
0 Better
DWorse
PILLOW:
D None Used
D Foam Rubber
D Feather
D Dacron
D Don't Know
DOther
ARE SYMPTOMS WORSE:
D Morning
0 Afternoon
D Evening
DNight
0 At Home
OAt Work
0 Other Location
SOME OF THE FOLLOWING MAY CAUSE YOUR SYMPTOMS OR MAKE THEM WORSE.
CHECK THOSE THAT DO.
0 In-doors
D Out-doors
D Weather Change
0 Wet Weather
0 Dry Weather
0 Windy Day
0 Hot Day
D Cold Day
0 Air-Conditioning
0 In Barns
D Damp Areas
D Hay, Circus
0 Mowing Lawn
D Dusty Environment
0 High Pollution Day
D Animals
D Cooking Odors
0 Smoke
0 Soap Powder
0 Insecticides
0 Paint Fumes
0 Perfumes
0 Cosmetics
0 Wave Sets
D Newspapers
DWool
0 Road Dust
0 Chemicals (list)
0 Milk or Milk Products
0 Eggs
0 Wheat Products
0 Nuts, Beans, or Seeds
0 Chocolate
0 Fish
DMeat
0 Fruit
D Vegetables
0 Alcoholic Beverages
DBeer
DWine
D Cheese, Mushrooms
D Aspirin
0 Drugs (list)
ACTIVITIES IN WHICH YOU SPEND A GREAT DEAL OF TIME:
0 Photography
0 Carpentry
0 Hobbies List:
0 Gardening
0 Painting
0 Other List:
0 Camping
0 Sewing
0 Sports List:
0 Cooking
0 Movies
Describe in your own words what bothers you the most:
Can you remember how the condition began and when?
USE THIS SPACE IF YOU WISH TO AMPLIFY ANY OF THE ABOVE ANSWERS
FAMILY HISTORY:
ASTHMA·
URTICARIA·
HAY FEVER·
ECZEMA·
HEADACHES (MIGRAINE) ·
OTHER:
PHYSICIAN'S FINDINGS