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Dr. Singh New Patient Questionnaire

Step 1 of 4

25%

Medication allergies
is the patient allergic to any medication? If so, please list the name of the medication and nature of the reaction (i.e. rash, diarrhea, etc.)
Past medical history
Please list any previous illnesses/injuries/surgeries
Previous allergy testing/allergy shots?
For children under 5 years of age
Birth weight
Full term/pretern

weeks
Breathing problems after delivery?
Breast fed/formula fed? Name of formula
Any problems with growth (weight or height)?
Immunizations-up to date?
- Yes
- No
Family history or allergies
- Asthrna
- Hay fever
- Sinus allergies
- Eczema
- Food allergies
- insect sting allergies
- medication allergies
- hives/angioedema
- immunodeficiency
- anaphylaxis
- exercise asthma
- nasal polyps
- GI reflux
- collagen disease
- cystic fibrosis
Social history
Occupation (for children-name of school and grade):
Missed school/work?
How much?
Does patient smoke now or in the past?
- Yes
- No
How many years?
How many packs/day?
Is patient exposed to smoke? If yes, where?
Hobbies
Environment
Patient exposed to pets? If yes, explain.
How old is your house?
Urban/suburban/rural
Stuffed toys
- few
- lots
Rooms
- Carpeted
- Hardwood
Indoor plants
- few
- several
Basement
- damp
- dry
Please note: additional questions will depend on the reason for your visit. Appropriate forms will be provided if necessary.

Respiratory Allergy Questionnaire
Nasal/sinus/ear/throat symptoms:
Severity of nasal/sinus symptoms
- mild
- moderate
- severe
Please grade symptoms on a scale of 1-4
- Spring
- Summer
- Fall
- Winter
Are symptoms worse in the morning upon awakening?
Triggers for nasal/sinus/ear/throat:
- Grass
- weeds
- trees
- cat
- dog
- dust
Mold/mildew
- raking leaves
- air conditioning
- basement
Weather
- cold
- heat
- wind
- smog
Chemicals
- paint
- perfurme
- soaps/detergents
- cosmetics
- aerosols
- smoke
- wool
- exercise
- pregnancy/menstruation
Foods: (please list)
How many sinus infections in the past year?
Ear infection?
Throat infections?
Chest symptoms
- cough
- wheezing
- congestion
- breathing difficulty
How long has the patient had chest symptoms?
MM slash DD slash YYYY
Duration of typical episode in day
Frequency of episodes in months
Frequency of episodes in year
breathing treatment time of medication
Oral steroids (Orapred/pediapred/prednisone)?
Antibiotics-name?
How many times does the patient have cough/wheezing/shortness of breath?
Daytime
- Daily
- 12-6 times a week
- less than once a week
Nighttime
- less than 2 x month
- 2 x month
- more than 2 x month
How often do you use rescue inhaler (puffer)
- daily
- 2-6 times a week
- less than 1 time a week
How many ER/Urgent doctor visits for asthma in the past 6 months?
Ever hospitalized or admitted to intensive care unit for asthma? If yes, please explain...
Upper respiratory infections (head colds/sinus infections)
- Grass
- weeds
- trees
- cat
- dog
- dust
Mold/mildew
- raking leaves
- air conditioning
- basement
Weather
- cold
- heat
- wind
- smog
Chemicals
- paint
- perfume
- soaps/detergents
- cosmetics
- aerosols
- smoke
- wool
- pregnancy/menstruation
Foods: (please list):
Does patient have recurrent bronchitis/croup/asthma./reactive airway disease/pneumonia?
Does patient have prolonged chest congestion following a virus/cold?
- Yes
- No
Does patient have exercise-induced cough, wheezing oishortness of breath?
- Yes
- No

At what age did eczema start?
Location
- scalp
- face
- chest
- abdomen
- back
- arms
- legs
Ttiggers
Seasonal
- spring
- summer
- fall
- winter
- Soap
- shampoo
- woolen clothing
- jeans
Foods: (please specify)
Hives
How long has the patient had hives?
Location
- scalp
- face
- neck
- chest
- abdomen
- back
- arms
- legs
Itching
- mild
- moderate
- severe
Is itching worse at night?
Does the rash (hives) come and go, keep moving or persist in one sot for more than 24 hours?
Any bunring/pain or bruising at the site of the rash (hives)?
Lip swelling, tongue swelling, throat swelling, breathing problems associated with hives?
Triggers
- soap
- shampoo
- woolen clothing
- cosmetics
- detergents
- conditioners
Pressure areas
- belt line
- bra line
- tight socks
Triggers
- Heat
- exercise
- sweating
- cold exposure
- sun
- pressure
- vibration
Medication
- aspirin
- Motrin
- Aleve
- and other pain relievers of the NSAID family
Foods:
please list any foods, dyes, wine, MSG, that may be thought to cause hives.
Bee Sting Allergy
When did the reaction(s) occur?
Describe the setting:
Local swelling or
Generalized hives, eyelid swelling, lip and tongue swelling, throat swelling, Breathing problems, dizziness or loss of consciousness
Food or medication allergy:
For each of the foods or medication suspected of causing a reaction, list the date when the reaction occurred, symptoms during the reaction and how long it took to resolve,

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Contact Information

5793 Widewaters Parkway, Suite 250 Syracuse, NY 13214

https://www.aaracny.com

Contact Information

1-315-478-2339 / 1-315-478-0502 1-315-478-0439 (Fax)

AARA © 2018 | All Rights Reserved

Spring is upon us and allergy issues are increasing. We are accepting new patients over 6 years of age and have generally short wait times.

All patients are seen by a Physician and not a Physician Extender. Please inspect the variety of issues we treat and if you need assistance,

Please give us a call.

Thank you.