ASTHMA & ALLERGY SPECIALISTS, LLC Name:______________________________ DOB:___________ Primary MD:____________Date:_________ Reason for today’s visit: Sick ______ Routine follow-up ______ Allergy testing ______ Extract refill ______ What is your main problem?_____________________________ Current Allergy Symptoms or Problems: (circle all that apply) runny/stuffy nose post-nasal drip sneezing itching of eyes, ears, nose, throat, or skin sinus pain or pressure discolored mucus headache ears pop or click wheeze cough tight chest short of breath other:__________________________________ skin rash medication allergy food allergy How often are symptoms present: daily ______ days/wk ______ days / month never For Asthmatic Patients: Asthma Control Test (circle one answer per question) 1) On average, over the past 4 weeks...How much of the time did your asthma keep you from getting as much done at work, school or at home? Often Seldom Rarely Never 2) How often have you had shortness of breath? Often Seldom Rarely Never 3) How often did your asthma wake you up at night? +4 nights / wk 2-3 nights / wk once / wk never 4) How often do you use your rescue inhaler (albuterol, Maxair...) or nebulizer medication (albuterol, Xopenex...)? 3 or more times / day 1-2 times / day 2-3 times / wk Less than 2 times / wk 5) How well would you rate your asthma control during the past 4 weeks? Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled REVIEW OF SYSTEMS (circle all that apply) Do you use tobacco? Y N CONSTITUTIONAL: fever weight change other: NEUROLOGICAL: headache other: EYES: blurry vision itching other: EARS NOSE THROAT: snoring nasal drainage post-nasal drip ear pain/pressure other: PULMONARY: wheeze cough SOB other: CARDIOVASCULAR: high blood pressure irregular heart beat chest pain other: GASTROINTESTINAL: vomiting diarrhea constipation indigestion other: GENITO-URINARY: difficulty urinating prostate (men) or menstrual problems (women) other: ENDOCRINE: thyroid problem diabetes other: HEME/ONCOLOGY: cancer (please explain)_________________________________________ other: JOINTS/RHEUMAT: arthritis joint swelling joint pain other: SKIN: rash hives eczema itching other: PSYCHOLOGICAL: anxiety depression ADD/ADHD other: Are you pregnant? Y N If “yes” what is your “due date”? _________________ PLEASE LIST ALL OF YOUR CURRENT MEDICATIONS AND DOSAGE (please include medication prescribed by all of your doctors and any over-the-counter products Drug Name Drug Strength How often do you take it? ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ ______________________________ _____________________________ ____________________________ Nurse Init:___________ Rev 06/2012 Form 47 Downloaded from internet