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 AND BRING IT TO YOUR APPOINTMENT.
APPOINTMENT DATE____________________
NAME_______________________________________________________
DATE OF BIRTH_________________________
PHYSICIAN (FAMILY DOCTOR, INTERNIST, PEDIATRICIAN)
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HOW DID YOU FIND OUT ABOUT OUR OFFICE?
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WHAT DIFFICULTIES CONCERN YOU THE MOST?
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PLEASE NOTE / CIRCLE YOUR 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
PLEASE SPECIFY____________________________________________________________
WHEN DO YOU TYPICALLY HAVE WORST SYMPTOMS?
JAN_____ FEB_____ MAR_____ APR_____ MAY_____ JUN_____
JUL_____ AUG_____ SEP______ OCT_____ NOV______ DEC_____
WHEN DO YOU TYPICALLY HAVE THE LEAST SYMPTOMS?
JAN_____ FEB_____ MAR_____ APR_____ MAY_____ JUN_____
JUL_____ AUG_____ SEP______ OCT_____ NOV______ DEC_____
ARE YOUR SYMPTOMS YEAR-ROUND? YES___ NO___
PLEASE CIRCLE THE ITEMS WHICH WORSEN YOUR SYMPTOMS:
TREES GRASSES CUT GRASS WEEDS RAGWEEDS
DUST MOLDS MILDEW
CATS DOGS HORSES HAMSTERS GUINEA PIGS
OTHER ANIMALS (SPECIFY)__________________________________________________
MOSQUITOES BEES WASPS FLIES
SMOKE PERFUMES ODORS AIR CONDITIONING
COLD AIR HOT AIR HUMID AIR FOG RAIN
WEATHER CHANGES STORMY WEATHER SUNLIGHT
HOME WORKPLACE (SPECIFY TYPE)_____________________________________
CAR TRUCK VAN BOAT MOTOR HOME
EXERCISE STRESS DURING SLEEP
OTHER____________________________________________________________________
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE:
YES NO
ALLERGIES? ____ ____
HAY FEVER? ____ ____
ASTHMA? ____ ____
SINUS PROBLEMS? ____ ____
NASAL POLYPS? ____ ____
HIVES (URTICARIA)? ____ ____
ECZEMA? ____ ____
MIGRAINE HEADACHES? ____ ____
FREQUENT INFECTIONS? ____ ____
DO YOU FEEL WORSE AFTER EATING OR DRINKING ANY PARTICULAR FOODS? NO___ YES___
PLEASE SPECIFY AND EXPLAIN_________________________________________
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HAVE YOU HAD ANY DIFFICULTIES FROM INSECT STINGS OR BITES? NO___ YES___
WAS THIS LIMITED TO THE AREA OF THE STING / BITE? YES___ NO___
DID YOU HAVE ANY DIFFICULTIES AWAY FROM THE STING / BITE? NO___ YES___
PLEASE SPECIFY TYPE OF INSECT, YEAR OCCURRED, TYPE OF
DIFFICULTY___________________________________________________________
_______________________________________________________________________
FAMILY HISTORY
PLEASE INDICATE IF ANY OF YOUR RELATIVES HAVE EVER HAD:
ALLERGIES ASTHMA ECZEMA HIVES
MOTHER ___________ ________ ________ ______
FATHER ___________ ________ ________ ______
MOTHER’SPARENTS ___________ ________ ________ ______
FATHER’S PARENTS ___________ ________ ________ ______
BROTHERS ___________ ________ ________ ______
SISTERS ___________ ________ ________ ______
CHILDREN ___________ ________ ________ ______
UNCLES ___________ ________ ________ ______
AUNTS ___________ ________ ________ ______
HAVE YOU BEEN TO AN ALLERGIST BEFORE? NO____ YES____
DOCTOR SEEN____________________________ YEAR LAST SEEN______________
REASON SEEN________________________________________________________________________________
DID YOU HAVE ALLERGY TESTING? NO___ YES___
RESULTS_____________________________________________________________________________
DID YOU RECEIVE ALLERGY INJECTIONS? NO____ YES____
FIRST INJECTION___________________ LAST INJECTION___________________
HOW OFTEN? _________________________________
DIDYOU HAVE ANY PROBLEMS? YES___ NO___
WERE THE INJECTIONS HELPFUL? YES___ NO___
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________
CIRCLE AND INDICATE THE NUMBER OF THE ANIMALS IN YOUR HOME:
DOGS___ CATS___ GUINEA PIGS___ HAMSTERS___ RABBIT___
HORSES___ GERBILS___ BIRDS___ LIZARDS___ TURTLES___ FISH___
OTHER____________________________________________
ANY PRESCRIPTION MEDICATIONS FOR ANY MEDICAL CONDITION IN THE LAST YEAR? NO____ YES___
NAME STRENGTH TIMES / DAY
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
__________________________ ___________ ____________
DO YOU HAVE ANY MEDICATION ALLERGIES? NO_____ YES_____
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HAVE YOU EVER HAD ANY OPERATIONS / SURGERIES? NO___ YES___
PLEASE LIST ALL THAT HAVE BEEN PERFORMED:
________________________________________________________________________________________________________
HAVE YOU EVER HAD ANY OVERNIGHT HOSPITAL STAYS (NON-SURGICAL)? NO___ YES___
PLEASE LIST EACH INCLUDING REASONS:
________________________________________________________________________________________________________
HAVE YOU EVER REGULARLY USED TOBACCO PRODUCTS? NO____ YES____
CIGARETTES______ NUMBER / DAY_______ NUMBER OF YEARS_______ QUIT IN _______
CIGARS_____ NUMBER / DAY_______ NUMBER OF YEARS_______ QUIT IN _______
PIPE_______ TIMES / DAY_______ NUMBER OF YEARS_______ QUIT IN _______
CHEWING_______ TIMES / DAY_______ NUMBER OF YEARS _______ QUIT IN _______
HAVE YOU EVER HAD A POSITIVE TUBERCULOSIS (TB) TEST? NO_____ YES_____
HAVE YOU EVER HAD A FLU SHOT (INFLUENZA)? NO_____ YES_____
LAST RECEIVED IN ______________
HAVE YOU EVER HAD A PNEUMOVAX SHOT (“PNEUMONIA SHOT”)? NO_____ YES_____
LAST RECEIVED IN ______________
IF NOT ALREADY ANSWERED ABOVE, HAVE YOU EVER RECEIVED MEDICAL CARE FOR THE FOLLOWING?:
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___
______________________________________________________________________ ______________________________
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 ___
