PEDIATRIC ALLERGY QUESTIONNAIRE Today’s Date: Patient’s Name: Date of Birth: Age: Address: Phone: Primary Care Physician/Pediatrician Name: Phone: Address: Fax: Referring provider , if different from primary care physician: Name: Phone: Address: Fax: 1. CHIEF COMPLAINT (reason for visit): 2. PRIOR ALLERGY EVALUATION AND TREATMENT: Has your child been previously evaluated for allergies? Yes No ( If yes, complete this section) Has your child ever had an allergy skin test? Yes No If yes, Date: Results: 1
Has your child ever had an allergy blood test? Yes No If yes, Date: Results: Has your child ever received immunotherapy (allergy shots)? Yes No If yes, Dates: For what allergies? 3. FOOD REACTIONS: Yes No ( If yes, complete this section) A.How long was your child breastfed?
4. ASTHMA HISTORY : Yes No ( If yes, complete this section) Age of onset: Frequency of attacks: Most recent exacerbation: Has your child had bronchiolitis (i.e. RSV) in the past? Yes No Has your child ever needed any of the following for asthma? (Please answer with the most recent first.) Hospital admissions: Emergency room visits: ICU admissions: Intubations: Symptoms : Wheeze Cough Sputum Exercise Intolerance Chest Pain Shortness of breath 3
Night time cough : Yes No Season worse in : Winter Spring Summer Fall Triggers : 5. ALLERGY & ASTHMA TRIGGERS: (Please select choices, check “Yes” or “No”, and list symptoms) Yes No Symptoms Grass exposure Raking leaves Mowing lawn Damp areas with mold and mildew Sweeping Dusting Vacuuming Smog Air Pollution
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- Spring '14