Allergy Assessment Form

Allergy Assessment Form

Name____________________________________ Age__________ Sex_______________ Date__________________

I. Chief Complaint: ___________________________________________________________________________________ II. Present Illness: _____________________________________________________________________________________ III. Collateral allergic symptoms:
Eyes: Pruritus________ Burning _______ Lacrimation_______ Swelling _______ Injection ______ Discharge ________
Ears: Pruritus _______ Fullness ______ _ Popping _______ Frequent infections ___________
Nose: Sneezing ______ Rhinorrhea______ Obstruction ________ Pruritus_______ Mouth-Breathing _______________ Purulent Discharge ______________
Throat: Soreness
Effect of hospitalization: _____________________________________________________________________________
Effect of specific environments: _______________________________________________________________________
Do symptoms occur around: __________________________________________________________________________ old leaves ____________ hay _______________ lakeside___________ barns ___________ summer homes _________ damp basement ___________ dry attic _______________ lawn mowing _____________ animals _______________ others ____________________________________
Do symptoms occur after eating: cheese _________ mushrooms _________ beer _________ melons _________ bananas_________ fish _________ nuts _________ citrus fruits _________ other foods (list) _____________________________________________________________________________
Home: city _________ rural _________ house _________ age _________ apartment _________ basement _________ damp _________ dry _________ heating system _________ pets (how long) ___________ dog __________ cat ___________ others ___________________________
Bedroom: TYPE AGE Living room: TYPE AGE
Pillow ____________ ____________ Rug ____________