DO NOT MAIL    PLEASE HAND CARRY 

PATIENT ALLERGY SURVEY SHEET

NAME_____________________________________________  DATE________________ AGE_____ 

REFERRING PHYSICIAN_____________________________PHONE NUMBER________________ 

TO WHOM DO YOU WISH A CONSULTATION LETTER SENT?  (Include your doctor’s address) ____________________________________________________________________________

___________________________________________________________________________________ 

Please fill in blanks and circle other applicable answers. Feel free to make additional comments. Base 

your answers on your own observations and not on what you have been told by others or what you may 

know about previous skin test results. Though these questions are  rather detailed, the information 

provided will be of major assistance to the doctor. 

DESCRIBE YOUR MAJOR ALLERGY PROBLEM IN YOUR OWN WORDS: 

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DO YOU RELATE THIS PROBLEM TO ANYTHING IN YOUR ENVIRONMENT?  FOR EXAMPLE, IS IT MADE WORSE BY POLLENS (GRASS, WEEDS), MOLDS, OR FOODS?  IS IT WORSE AT HOME OR AWAY, OR AT WORK, OR WITH CERTAIN HOBBIES, OR EXERCISE?  

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WHEN DID THIS ALLERGY PROBLEM BEGIN? _______________________________________________ 

WHERE WERE YOU LIVING AT THE TIME? __________________________________________________ 

HAVE YOU SEENOTHER SPECIALISTS ABOUT THIS PROBLEM?  Yes  No 

IF YES, YOU SHOULD MAKE AN ATTEMPT  TO HAVE RECORDS FORWARDED TO THE ALLERGY CLINIC. 

I. PAST MEDICAL PROBLEMS:

CHILDHOOD ILLNESSES:___________________________________________________________ 

___________________________________________________________________________________

___________________________________________________________________________________ 

PREVIOUS SURGERY: 

OPERATION          YEAR          PLACE

_____________________________ ___________________  ______________________ 

_____________________________ ___________________  ______________________ 

_____________________________ ___________________  ______________________ 

_____________________________ ___________________  ______________________ 

_____________________________ ___________________  ______________________ 

AS A CHILD, DID YOU HAVE?  ECZEMA    Yes  No 

            ASTHMA                   Yes    No 

            HIVES                       Yes    No 

            HAY  FEVER             Yes    No 

            FOOD  ALLERGY      Yes    No 

II  FAMILY HEALTH

    AGE*    ILLNESSES**

Mother ________  _______________________________________________________ 

Father  ________   _______________________________________________________ 

Brother ________  _______________________________________________________ 

Brother ________  _______________________________________________________ 

Brother ________  _______________________________________________________ 

Sister  ________   _______________________________________________________ 

Sister  ________   _______________________________________________________ 

Sister  ________   _______________________________________________________ 

Other  ________  _______________________________________________________ 

      AGE*     ILLNESSES**

Children   M F ________  _________________________________________________ 

      M F ________  ______________________________________________________ 

      M F ________  ______________________________________________________ 

      M F ________  ______________________________________________________ 

*AGE:  CURRENT AGE OR AGE AT EXPIRATION (Circle if deceased). 

** ILLNESSES:  IN ADDITION TO ALLERGIC DISEASE (ASTHMA, HAYFEVER, ECZEMA, FOOD ALLERGIES), LIST OTHER DISEASES SUCH AS HIGH BLOOD PRESSURE, DIABETES, CANCER, ULCER, ETC.   

II. OCCUPATIONAL HISTORY:

WHAT IS YOUR CURRENT OCCUPATION? _________________________________________________ 

EMPLOYER: ________________________________________________________________________ 

HOW LONG HAVE YOU WORKED AT YOUR CURRENT JOB? __________________________________ 

DESCRIBE YOUR CURRENT WORK CONDITIONS IN AS MUCH DETAIL AS POSSIBLE 

(VENTILATION, FUMES OR DUST, EXACT JOB DESCRIPTION:  __________________________________ 

___________________________________________________________________________________

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ARE YOU EXPOSED TO:    NAMES IF POSSIBLE

CHEMICALS          YES    NO _________________________________________________ 

WOOD DUSTS     YES    NO _________________________________________________ 

PLASTIC FUMES   YES    NO _________________________________________________ 

ROCK DUSTS       YES    NO _________________________________________________ 

ANIMALS              YES    NO _________________________________________________ 

MOLDY HAY        YES    NO _________________________________________________ 

FLOUR                 YES    NO _________________________________________________ 

EPOXY                 YES    NO _________________________________________________ 

ASBESTOS           YES    NO _________________________________________________ 

OTHER:_____________________________________________ 

OTHER:_____________________________________________

IV: PLACES OF EMPLOYMENT PRIOR TO CURRENT JOB 

DATES    EMPLOYER                JOB

___________  __________________________________________   _______________ 

___________  __________________________________________   _______________ 

___________  __________________________________________   _______________ 

___________  __________________________________________   _______________ 

___________  __________________________________________   _______________ 

___________  __________________________________________   _______________ 

HAVE YOU EVER BEEN (OR ARE YOU NOW) DISABLED DUE TO A WORK INJURY?  

Yes   

No 

(Details)___________________________________________________________________________ 

__________________________________________________________________________________ 

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V. SOCIAL HISTORY

A. GENERAL

EDUCATION (Highest Level/Major/Degree (s) ______________________________________ 

BIRTHDAY _________________ PLACE OF BIRTH _________________________________ 

 ARE YOU MARRIED? __________________  DATE:________________________________ 

 PRIOR MARRIAGES? ________________________________________________________ 

 SPOUSE’S OCCUPATION? ____________________________________________________ 

 WERE YOU EVER IN THE ARMED SERVICES?  Yes ______________  No________________ 

 TRAVEL OUTSIDE U.S.A. IN THE PAST 12 MONTHS? ________________________________ 

B. HABITS:

DO YOU (OR HAVE YOU EVER) SMOKED?  Yes  No   

IF YES, ANSWER BELOW: 

SMOKE:  Cigarettes – Cigar – Pipe (Circle) 

STARTED SMOKING AT WHAT AGE?  _______ 

BRAND OF CIGARETTE __________________________ Filter / nonfilter 

TOTAL NUMBER OF YEARS THAT YOU SMOKED: _________________ 

AVERAGE NUMBER OF CIGARETTES (OR PACKS) SMOKED  PER DAY DURING THE TIME THAT YOU HAVE SMOKED (OR THAT YOU SMOKED PIOR TO QUITTING): ____________________________

HAVE YOU QUIT SMOKING?  _____________  IF SO, WHEN? _______________________ 

DOES ANYONE IN YOUR HOUSEHOLD SMOKE?    Yes            No 

IF YES, WHO: _____________________________________________________________ 

DO YOU DRINK ALCOHOLIC BEVERAGES?      Yes    No 

IF YES, ANSWER BELOW:     BEER   WINE   LIQUOR

I DRINK: 

Amount of each ____________ cans/week  ______glasses/week  ________ ounces/week

  DO YOU USE ANY PRESCRIPTION MEDICINE REGULARLY?    Yes  No 

  IF YES, PLEASE LIST: ______________________________________________________ 

  _______________________________________________________________________ 

DO YOU USE ANY  NON-PRESCRIPTION MEDICINE (e.g. NOSE SPRAYS OR DROPS, ASPIRIN, VITAMINS, TONICS)?   Yes   No 

IF YES, PLEASE LIST: _______________________________________________________ 

 _______________________________________________________________________ 

DO YOU (OR HAVE YOU EVER) USED PLEASURE OR RECREATIONAL DRUGS (e.g. POT, COCAINE, LSD, AMPHETAMINES)?   Yes    No 

IF YES, DESCRIBE EXPOSURE: ________________________________________________ 

 ________________________________________________________________________ 

AVERAGE HOURS OF SLEEP:  ______________ Hrs/day 

DO YOU EXERCISE REGULARLY?   Yes No 

IF YES, DESCRIBE:  _________________________________________________________ 

 ________________________________________________________________________ 

C. HOBBIES:

PLEASE CIRCLE YOUR HOBBIES.  STAR (*) ANY WHICH SEEM TO 

AGGRAVATE YOUR SYMPTOMS.  

BIRD STUDY     MOVIES/T.V.      BOWLING       PAINTING (WATERCOLOR, OILS, ENAMEL)  

CAMPING     PHOTOGRAPHY    COOKING      READING     COIN COLLECTING    SEWING 

FISHING      SCULPTURE     GARDENING     STAMP COLLECTING      GOLFING    

STAINED GLASS     HIKING      WELDING    HUNTING      WOOD WORKING      KNITTING    

OTHER _____________________________________ 

D. DRUGS:

DO YOU HAVE ANY DRUG ALLERGIES?    Yes    No 

HAVE YOU EVER HAD AN ALLERGIC OR TOXIC REACTION TO ANY OF THE FOLLOWING DRUGS? 

ASPIRIN   Yes No  ERYTHROMYCIN  Yes No 

NOSE DROPS  Yes No  OTHER ANTIBIOTICS Yes No 

LAXATIVES  Yes No  HORMONES  Yes No 

SEDATIVES   Yes No  ANTITOXINS  Yes No 

TONICS   Yes No  ANTIHISTAMINES Yes No 

NERVE MEDICINES Yes No  CORTISONE-LIKE 

VITAMINS   Yes No   STEROID DRUGS Yes No 

SULFA DRUGS  Yes No   OTHERS _______________________ 

PENICILLIN   Yes No 

DO YOU EVER USE ASPIRIN OR DRUGS CONTAINING ASPIRIN (e.g. BUFFERIN, CORICIDEN, 4-WAY COLD  TABLETS, MIDOL, ANACIN, NYQUIL, ETC.    Yes    No 

IF YES, HOW MANY TABLETS PRE MONTH?  ___________________ 

E. FOODS:

DO ANY FOODS MAKE YOUR SYMPTOMS WORSE?  Yes  No 

IF YES, PLEASE NAME THEM:  _________________________________________________ 

_________________________________________________________________________ 

  SYMPTOMS PRODUCED: ____________________________________________________ 

  HAVE ANY SPECIAL DIETS BEEN TRIED IN THE PAST? Yes No 

  IF YES, TYPE OF DIET:  ______________________________________________________ 

  WERE THE RESULTS GOOD?  _________________________________________________ 

F.  PSYCHOLOGICAL FACTORS:

 HOW WOULD YOU DESCRIBE YOURSELF (Circle all appropriate adjectives which 

reflect your behavior).  

 CALM   MOODY  NERVOUS  BAD TEMPERED 

 WELL ADJUSTED  DEPRESSED ANXIOUS  IMPATIENT 

 OUTGOING   MOROSE  TENSE  FEARFUL 

G.   HOME:

LOCATION OF HOME?    TYPE OF HOUSE?   HEATING SYSTEM?

 COUNTRY    FRAME   HOT AIR ELECTRIC 

 SUBURBAN    BRICK   HOT WATER GAS 

 CITY     MOBILE/TRAILER STEAM PROPANE 

      APARTMENT  WOOD STOVE  OIL 

                    SPACE  HEATER 

 HUMIDIFIER IN HOME?  Yes  No 

 AIR FILTRATION SYSTEM? Yes  No 

 AIR CONDITIONER?  Yes  No 

 APPROXIMATE AGE OF HOUSE?  ______________ YEARS 

 HOW LONG HAVE YOU LIVED IN THE HOUSE?  ____________ YEARS 

 HAVE YOU HAD RECENT INSULATION   Yes  No 

  TYPE: _________________________________________ 

 DO YOU HAVE   CARPTETING   Yes  No 

          DRAPERY        Yes    No 

          FEATHER  MATTRESS    Yes    No 

          FEATHER  PILLOW    Yes    No 

          FEATHER  COMFORTER    Yes    No 

     UPHOLSTERED FURNITURE Yes  No 

     STUFFED TOY ANIMALS Yes  No 

          LIVING  PLANTS      Yes    No 

     WALL HANGINGS  Yes  No 

          CAT  LITER  BOX      Yes    No 

     DAMP BASEMENT  Yes  No Page 7 

  DO YOU HAVE PETS? If so, how many? _____ CATS_______DOGS    

_______BIRDS_______GERBILS______HORSES______HAMSTERS    

OTHERS: _________________________ 

  ARE YOUR PETS EVER IN YOUR BEDROOM?  Yes  No 

  IS YOUR HOME NEAR:  Stables   Dairies   Barns   Animals   Factories  ( Please Circle) 

H. FACTORS PRECIPITATING SYMPTOMS: (Please circle any that you feel make your 

symptoms worse) 

ALLERGENS   

 GRASS  WET LEAVES  ANIMAL DANDER (CAT, DOG) 

 WEEDS  BARN DUST  EATING CHEESE 

 TREES  HOUSE DUST  EATING MUSHROOMS 

 HAY   DAMP PLACES  DRINKING WINE 

 FLOWERS  COTTON LINT  DRINKING BEER 

INFECTION

 DO YOUR SYMPTOMS GET WORSE WITH HEAD OR CHEST COLDS?  Yes  No 

 DO YOUR SYMPTOMS FLARE WITH SINUS INFECTIONS?         Yes  No 

EXERCISE

 DO YOUR SYMPTOMS GET WORSE WITH EXERTION OR EXERCISE?   Yes No 

  WHAT TYPES OF EXERTION ARE WORSE FOR YOU?  ____________________ 

PHYSICAL AGENTS

  DO YOU HAVE WORSE SYMPTOMS AFTER EXPOSURE TO THE FOLLOWING? 

  HEAT   Yes  No   WEATHER CHANGES Yes  No 

  COLD   Yes  No  DAMPNESS   Yes  No 

  FIELD BURNING Yes  No  AIR CONDITIONING Yes  No 

  DRAFTS  Yes  No  POLLUTION/SMOG Yes  No 

  SUNLIGHT  Yes  No  VOLCANIC ASH  Yes  No 

MISCELLANEOUS

  DO YOU HAVE WORSE SYMPTOMS AFTER EXPOSURE TO THE FOLLOWING? 

  COSMETICS     Yes  No TOOTHPASTE   Yes  No 

  PERFUMES      Yes  No INSECTICIDES   Yes  No 

  WAVE SETS     Yes  No  PAINT, VARNISH FUME  Yes  No 

  CHEMICALS     Yes  No CLOTHING STORES  Yes  No 

  HOUSEHOLD CLEANERS Yes  No WOOL/COTTON LINT  Yes  No 

  MOUTHWASH     Yes  No FOOD COOKING ODORS Yes  No 

  NEWSPAPER     Yes  No Page 8 

RASHES FROM CONTACTANTS

  HAVE YOU EVER HAD A REPETITIVE RASH FROM THE FOLLOWING? 

  IF YES, DESCRIBE TYPE OF MATERIAL. 

  POISON IVY     YES / NEVER____________________ 

  POISON SUMAC     YES / NEVER____________________ 

  POISON OAK     YES / NEVER____________________ 

  RASHES FROM OTHER PLANTS  YES / NEVER ____________________ 

    RASHES  FROM  WORK        YES / NEVER ____________________ 

  RASHES FROM OINTMENTS   YES / NEVER ____________________ 

  RASHES FROM COSMETICS   YES / NEVER ____________________ 

  RASHES FROM CLOTHING   YES / NEVER ____________________ 

  RASHES FROM METALS    YES / NEVER ____________________ 

  RASHES FROM HOBBIES    YES / NEVER ____________________ 

  RASHES FROM HOUSEHOLD AGENTS YES / NEVER ____________________ 

INSECT STINGS

HAVE YOU EVER HAD AN UNUSUAL REACTION FROM AN INSECT STING OR 

BITE?       Yes  No 

 TYPE OF INSECT: ______________________________________________________ 

TYPE OF REACTION: ___________________________________________________ 

 ______________________________________________________________________ 

 ______________________________________________________________________ 

IS THERE ANY OTHER PERTINENT INFORMATION ABOUT EXPOSURE TO 

ENVIRONMENTAL ALLERGENS THAT YOU CAN GIVE US?  ___________________________ 

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___________________________________________________________________________________ Have you had significant medical problems with any of the following organ systems?   

If you have, please circle them, and then feel free to provide any additional information in the 

space below.  Thank you. 

Skin – skin cancer, eczema, psoriasis, hives, swelling of the skin   

Eyes – glaucoma, cataracts, allergic eye symptoms, including itchy, watery, or red eyes 

Ears – decreased hearing, tumors, ear fullness, ear infection 

Nose – nasal congestion, runny nose, nasal pain, sinus pain, sinus infection, history of nasal 

trauma, history of surgery of the nose, tonsils, adenoids, or sinuses 

Mouth – chronic sore throats, oral cancer, hoarseness, chronic throat clearing 

Neck – swollen glands, thyroid problems, thyroid cancer, swollen thyroid, swollen windpipe or 

larynx 

Chest – Shortness of breath, wheezing, coughing, chest tightness, chest pain or pressure, night 

time cough, coughing up blood, shortness of breath with exercise, waking up short 

of breath at night 

Heart  – history of heart disease or heart attack, fast heart beat, extra or skipped heart beats, 

history of abnormal heart rhythm (such as supraventricular tachycardia (SVT), 

ventricular tachycardia (VT), atrial fibrillation, Wolf-Parkinson-White syndrome, 

history of angina, history of heart surgery, cardiac bypass surgery, heart valve 

replacement, history of high blood pressure, history of low blood pressure 

Digestive system – history of heartburn, gastroesophageal reflux, acid reflux, acid taste in the 

mouth, food sticking in the throat or chest area after swallowing, history of cancer 

of the stomach, bowel, or colon, bleeding in stool or with bowel movements, 

constipation, diarrhea 

Genitourinary system – history of bladder or kidney infections, kidney stones, prostate 

problems, frequent urination, having to get up to go to the bathroom more than 

once per night, history of bladder or kidney surgery, chronic kidney disease, 

dialysis, kidney transplantation, history of kidney stones 

Neurologic – history of seizures, currently taking seizure medicines, neuropathy, history of 

head trauma involving loss of consciousness, brain tumor, migraine headaches 

Bone and joint – history of arthritis, chronic analgesic use (such as aspirin, motrin, advil, 

ibuprofen, etc.), muscle aches, joint aches 

Additional  details if needed: 

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Thank you for helping us to care for you by providing this additional information. 

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