Allergy&Asthma Care (by Susan Weakly M.D.)

Patient Full Name:
Date of Birth: (ex. 01/01/2005)	/ / Age:
Email Address
Race:
Problem that you would like to discuss with Dr. Weakley:
How long have you had these symptoms:
What time of year are they worse?:
Occupation:
Time missed form school/work in past year :
Does your job cause/worsen your symptoms?:	Yes: No:
For what and how long?:
MEDICAL HISTORY
Patient Past Medical History - Have you ever had any of the following conditions?
Asthma:	Yes: No:
Bronchitis:	Yes: No:
Hay Fever:	Yes: No:
Pneumonia:	Yes: No:
Emphysema:	Yes: No:
Pleurisy:	Yes: No:
Lung Cancer:	Yes: No:
Heartburn/Reflux:	Yes: No:
Hives/Rash:	Yes: No:
Eczema:	Yes: No:
Sinusitis:	Yes: No:
Migraines:	Yes: No:
Diabetes:	Yes: No:
Heart Trouble:	Yes: No:
Hypertension:	Yes: No:
Stroke:	Yes: No:
Previous Hospitalizations/Surgeries/Serious Injuries? When?:
List of all current medications:
Do you have any drug allergies?:	Yes No To What?
PATIENT SOCIAL HISTORY
Marital Status:	S M W D
Use of Alcohol:	Never: Rarely Occasionally Daily
Use of tobacco:	Do you smoke? Yes: No: Have you ever smoked? Yes: No: If yes, when did you quit: How often did/do you smoke? Daily Occasionally Do you use other Tobacco Products: Yes: No: If no, have you ever? Yes: No: What Type? Pipe Cigars Chewing Tobacco How often did/do you use it? Daily Occasionally
Do other members of the household smoke?:	Yes: No: Who:
Excessive exposure at home or work to:	Fumes: Dust: Solvents: Airborne Particles: Noise:
FAMILY MEDICAL HISTORY
Do any of your family members or close relative have allergy, asthma or sinus problems:	Yes: No:
If yes, who and what problems do they have?:
REVIEW OF SYSTEMS

Please select any current personal medical symptoms:

Constitutional Symptoms

Good general health lately:

Yes: No:

Recent weight change:

Yes: No:

Fever:

Yes: No:

Fatigue:

Yes: No:

Headaches:

Yes: No:

Gastrointestinal

Abdominal pain:

Yes: No:

Peptic Ulcer:

Yes: No:

Frequent heartburn:

Yes: No:

GERD (Reflux):

Yes: No:

Integumentary (Skin)

Rash or itching:

Yes: No:

Hives:

Yes: No:

Change in skin color:

Yes: No:

Change in hair or nails:

Yes: No:

Eyes

Redness or itching:

Yes: No:

Corrective glasses or contacts:

Yes: No:

Glaucoma or other vision problems:

Yes: No:

Ear/Nose/Mouth/Throat

Hearing loss or ringing:

Yes: No:

Earaches, infections or drainage:

Yes: No:

Nose bleeds:

Yes: No:

Frequent nasal stuffiness:

Yes: No:

Runny nose:

Yes: No:

Postnasal drip:

Yes: No:

Frequent sinus infections:

Yes: No:

Mouth sores:

Yes: No:

Swollen glands in neck:

Yes: No:

Allergic/Immunologic

Skin or other adverse reaction to:

Penicillin or other antibiotic:

Yes: No:

Demerol/other narcotic:

Yes: No:

Novocain/other anesthetic:

Yes: No:

Aspirin/other pain reliever:

Yes: No:

Tetanus antitoxin/other serum:

Yes: No:

Iodine/methiolate/antiseptic:

Yes: No:

Other drugs/medications:

Yes: No:

Known food allergies:

Yes: No:

Environmental allergies:

Yes: No:

Cardiovascular

Heart trouble:

Yes: No:

Chest pain or angina pectoris:

Yes: No:

Palpitations:

Yes: No:

Short of breath when walking/lying flat:

Yes: No:

Swelling of feet, ankles or hands:

Yes: No:

Neurological

Frequent or recurring headaches:

Yes: No:

Light-headedness or dizziness:

Yes: No:

Numbness or tingling sensations:

Yes: No:

Convulsions or seizures:

Yes: No:

Head injury:

Yes: No:

Respiratory

Chronic or frequent coughs:

Yes: No:

Asthma:

Yes: No:

Shortness of breath:

Yes: No:

Wheezing or chest tightness:

Yes: No:

Endocrine

Thyroid disease:

Yes: No:

Glandular/hormone problem:

Yes: No:

Heat or cold intolerance:

Yes: No:

Excessive thirst or urination:

Yes: No:

Which of the following factors worsen your symptoms? Mark C for coughing, W for wheezing, S for shortness of breath, N for nasal symptoms, R for rash and H for hives.

Exercise:

Smoke:

Dust:

Irritants:

Pets:

Drugs:

Cold:

Dampness:

Colds/flu:

Alcohol:

Stress:

Insect bites:

Cosmetics:

Food:

Weather change:

Are your symptoms worse during the day or night ? or both

Do your symptoms wake you up at nights?

Yes: No:

Number of infections in the last 2 years:

Sinus:

Ear:

Chest:

Upper respiratory:

Throat:

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