ASTHMA & ALLERGY SPECIALISTS, LLC

Name:______DOB:______Primary MD:______Date:______

Reason for today’s visit: Sick ______Routine follow-up ______Allergy testing ______Extract refill ______

What is your main problem?______

Current Allergy Symptoms or Problems: (circle all that apply)

runny/stuffy nose post-nasal drip sneezing itching of eyes, ears, nose, throat, or skin

sinus pain or pressure discolored mucus headache ears pop or click

wheeze cough tight chest short of breath other:______

skin rash medication allergy food allergy

How often are symptoms present: daily ______days/wk ______days / month never

For Asthmatic Patients: Asthma Control Test (circle one answer per question)

1) On average, over the past 4 weeks...How much of the time did your asthma keep you from getting as much done at work, school or at home? Often Seldom Rarely Never

2) How often have you had shortness of breath? Often Seldom Rarely Never

3) How often did your asthma wake you up at night? +4 nights / wk 2-3 nights / wk once / wk never

4) How often do you use your rescue inhaler (albuterol, Maxair...) or nebulizer medication (albuterol, Xopenex...)?

3 or more times / day 1-2 times / day 2-3 times / wk Less than 2 times / wk

5) How well would you rate your asthma control during the past 4 weeks? Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled

REVIEW OF SYSTEMS (circle all that apply) Do you use tobacco? Y N

CONSTITUTIONAL: fever weight change other:

NEUROLOGICAL: headache other:

EYES: blurry vision itching other:

EARS NOSE THROAT: snoring nasal drainage post-nasal drip ear pain/pressure other:

PULMONARY: wheeze cough SOB other:

CARDIOVASCULAR: high blood pressure irregular heart beat chest pain other:

GASTROINTESTINAL: vomiting diarrhea constipation indigestion other:

GENITO-URINARY: difficulty urinating prostate (men) or menstrual problems (women) other:

ENDOCRINE: thyroid problem diabetes other:

HEME/ONCOLOGY: cancer (please explain)______other:

JOINTS/RHEUMAT: arthritis joint swelling joint pain other:

SKIN: rash hives eczema itching other:

PSYCHOLOGICAL: anxiety depression ADD/ADHD other:

Are you pregnant? Y N If “yes” what is your “due date”? ______

PLEASE LIST ALL OF YOUR CURRENT MEDICATIONS AND DOSAGE (please include medication prescribed by all of your doctors and any over-the-counter products

Drug Name / Drug Strength / How often do you take it?

______

______

______

______

______

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Nurse Init:______

Rev 06/2012 Form 47

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