ALLERGY AND ASTHMA CENTER OF MICHIGAN, P.C.
COLD AND FLU CENTERS
MICHIGAN RESPIRATORY HEALTH AND RESEARCH INSTITUTE
24120 MEADOWBROOK ROAD, SUITE 201 NOVI, MICHIGAN 48375
(248) 473-6400 FAX: (248) 473-4424 www.allergyinfo.org
PLEASE FILL OUT THIS QUESTIONNAIRE BEFORE YOU SEE THE DOCTOR.
APPOINTMENT DATE____________________
NAME_______________________________________________________
DATE OF BIRTH_________________________
PHYSICIAN (FAMILY DOCTOR, INTERNIST, PEDIATRICIAN)
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PLEASE NOTE YOUR CURRENT AREAS OF CONCERN:
NOSE: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
STUFFY RUNNY ITCHY SNEEZING POSTNASAL DRIP
SORE BLEEDING DECREASED SMELL AND / OR TASTE
SINUSES: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
PAIN PRESSURE DRAINAGE HEADACHE
EYES: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
ITCHING BURNING WATERING / TEARING REDNESS
SWELLING / PUFFINESS DRAINAGE PAIN
EARS: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
PAIN PRESSURE ITCHING DRAINAGE
RINGING DECREASED HEARING DISCHARGE
THROAT: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
SORE ITCHY DRAINAGE HOARSENESS
CHEST: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
COUGH – DRY COUGH – PRODUCTIVE WHEEZING
SHORTNESS OF BREATH PAIN / PRESSURE
SKIN: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
ITCHING RED DRY DRAINAGE RASH
HEAD: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
ACHE / PAIN DIZZINESS / BALANCE PROBLEM
OTHER: YES___ NO___
SYMPTOMS FOR_________ DAYS WEEKS MONTHS YEARS
IF YOU HAVE MOVED SINCE YOUR LAST VISIT, PLEASE CIRCLE ITEMS THAT DESCRIBE YOUR HOME:
HOUSE CONDOMINIUM APARTMENT MOBILE HOME
APARTMENT / CONDOMINIUM WITH MULTIPLE FAMILY RESIDENCES
LESS THAN 1 YEAR OLD 1 TO 10 YEARS OLD 11 TO 50 YEARS OLD OVER 50 YEARS OLD
BASEMENT CRAWLSPACE WALKOUT BASEMENT CONCRETE SLAB FOUNDATION
CENTRAL AIR CONDITIONING ROOM AIR CONDITIONING (LOCATION___________________________)
HEATING: FORCED AIR (DUCT) BASEBOARD RADIATOR WOOD BURNING STOVE
CENTRAL (FURNACE) HUMIDIFIER ROOM HUMIDIFIER DEHUMIDIFIER (REMOVES MOISTURE)
STANDARD, DISPOSIBLE FURNACE FILTER HIGH EFFICIENCY FURNACE FILTER
CENTRAL (FURNACE) AIR CLEANER ROOM AIR CLEANER (LOCATION_______________________)
IS YOUR HOME MOSTLY:
CARPET? BARE FLOORING (WOOD, TILE, LINOLEUM)?
DOES YOUR BEDROOM HAVE:
CARPET? BARE FLOORING (WOOD, TILE, LINOLEUM)?
IS YOUR BED:
MATTRESS? BOX SPRINGS? PLATFORM? BUNK? WATERBED? FUTON?
DO YOU HAVE ALLERGY COVERS ON YOUR:
MATTRESS? BOX SPRINGS? PILLOWS? COMFORTER?
HOW MANY PILLOWS ARE ON YOUR BED?
FEATHER_________ NON-FEATHER________
ANY PRESCRIPTION MEDICATIONS FOR ANY MEDICAL CONDITION IN THE LAST YEAR? NO____ YES___
NAME STRENGTH TIMES / DAY
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
HAVE YOU HAD ANY OPERATIONS / SURGERIES SINCE LAST SEEN HERE? NO___ YES___
PLEASE LIST ALL THAT HAVE BEEN PERFORMED:
________________________________________________________________________________________________________
HAVE YOU HAD ANY OVERNIGHT HOSPITAL STAYS (NON-SURGICAL) SINCE LAST SEEN HERE? NO___ YES___
PLEASE LIST EACH INCLUDING REASONS:
________________________________________________________________________________________________________
HAVE YOU RECEIVED MEDICAL CARE FOR THE FOLLOWING AREAS SINCE LAST SEEN HERE?:
DRUG OR ALCOHOL ABUSE: NO___ YES___
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WEIGHT CONTROL: NO___ YES___
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CHRONIC FATIGUE: NO___ YES___
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EARS: NO___ YES___
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NOSE (OTHER THAN ALLERGIES): NO___ YES___
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THROAT: NO___ YES___
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HEART: NO___ YES___
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HIGH BLOOD PRESSURE: NO___ YES___
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LUNGS (OTHER THAN ASTHMA): NO___ YES___
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STOMACH, BOWELS: NO___ YES___
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LIVER: NO___ YES___
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KIDNEYS / BLADDER: NO___ YES___
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GENITALS: NO___ YES___
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MUSCLES / JOINTS: NO___ YES___
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BREASTS: NO___ YES___
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SKIN / HAIR / NAILS: NO___ YES___
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BLOOD: NO___ YES___
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LYMPH GLANDS: NO___ YES___
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HEADACHES: NO___ YES___
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NUMBNESS, WEAKNESS, SEIZURES: NO___ YES___
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MOOD, ANXIETY, DEPRESSION: NO___ YES___
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DIABETES: NO___ YES___
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THYROID: NO___ YES___
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HORMONES: NO___ YES___
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CANCER: NO___ YES___
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HEPATITIS: NO___ YES___
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HIV / AIDS: NO___ YES___
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ARE YOU INTERESTED IN PARTICIPATING IN CLINICAL RESEARCH STUDIES IN OUR OFFICE? YES___ NO___
