Allergy Test QuestionnairePage two

Patient Name:DOB:Date:

Allergy Test

Questionnaire

Dr. Megdal  Dr. McCurdy 

Patient Name:DOB:Date:

Within the Last Year, have you had any of the FOLLOWING?

Check all that apply and circle the most troublesome one(s)

Section AChief Complaints
Have you been diagnosed with Fibromyalgia? Yes No
Do you have any of the following symptoms: Check all that apply and circle the most troublesome one(s)
Abdominal Pain / Bloating / Reduced Tolerance for Exercise
Jaw or Facial Tenderness / Nausea / Muscle Pain after Exercise
Tension or Migraine Headaches / Constipation / Feeling of Swelling without Actual SwellingIn Hands or Feet
Do you suffer from headaches? Yes No
How old were you when headaches started?
How long have you been experiencing them?
How often do your headaches occur?
What time of day do your headaches usually occur?
How long do the headaches last?
What causes the headache, if known?
What symptoms, if any, occur between headaches?
How severe is the headache pain using a scale from 1 (Mild) to 10 (Severe)
Section BAllergy History
Check all the symptoms experiencing: Check all that apply and circle the most troublesome one(s)
Nasal Congestion / Nasal Itch/Rub / Bad Breath
Fatigue/Irritability / Red Eyes / Snoring
Post Nasal Drip / Itchy Eyes / Mouth Breathing
Runny Nose / Sinus Infections / Nosebleeds
Sneezing / Discolored Drainage / Loss of Taste/Smell
Nasal Polyps / Headaches
Check all the causes of your symptoms: Check all that apply and circle the most troublesome one(s)
Dust / Mold/Mildew / Time of Day – AM/PM
Fall Pollen / Mustiness/Dampness / Home
Springtime Pollen / Indoors / Workplace
Cut Grass/Rake Leaves / Outdoors / Food:
Dog / Weather Changes / Rain
Cat / Smoke / Strong Odors
Other Animals / Feathers / Temperature Changes
Do your symptoms occur year around seasonal  both
Have you had sinus x-ray or CT scan? Yes No
Section DFamily History
Have you or anyone in your family been diagnosed with asthma? Yes NoRelationship:
Is there anyone else in your family who has headaches? Yes NoRelationship:
CONTINUED ON BACK PAGE….
Section CEnvironmental Survey
Where do you live? House Apartment Condo Trailer
How long have you lived there?How old is it?
Pets
Cat Indoor Outdoor Both
Dog Indoor Outdoor Both
Other: Indoor Outdoor Both
Smokers in the house? Yes No
Is your home air conditioned? Yes No
Do you keep your windows opened? Yes No
Do you have moisture problems in your home? Yes No
Do you have a basement? Yes No
Bedroom: Type of bed Regular Waterbed/Wavelesswaterbed/Wave
Bedroom: Plastic encasement of mattress Yes No
Bedroom: Type of pillow Feather Synthetic Cotton
Bedroom: Type of floor Carpet Wood Vinyl Flooring
If recommended, would you consent to Allergy Testing?  Yes  No
If you answered yes, may we forward your questionnaire and demographics to our testing company for review?  Yes  No

S:/FormsPDF/PatientForms/allergytestquestionaireRevised 08/05/14