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Allergy Questionnaire

Allergy Questionnaire

Please click here to download a copy of the Allergy Questionnaire, print and bring it with you to your appointment, or complete the form below and submit it electronically.

DEMOGRAPHICS

Patient Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Parent 1 Name (if applicable)

First Last

Parent 2 Name (if applicable)

First Last

Address

Street Address Address Line 2 City State Zip

Work Phone

Patient or Parent Employer(s)

Referred by

Pharmacy of Choice

Primary Care Physician

TODAY'S VISIT

Reason for your visit today

What season(s) do your symptoms occur (please list all)

What triggers your symptoms (pollen, animals, mold, dust, pollution, weather and season changes, foods, other)

Are symptoms worse day, night, or both

Are symptoms worse at home and/or outside the home

Any other relevant details

ALLERGY AND ASTHMA HISTORY

Asthma

Yes

No

Have you ever been hospitalized for asthma?

Yes

No

Seasonal or indoor allergies

Yes

No

Food allergies

Yes

No

Eczema

Yes

No

Medication allergies

Yes

No

Skin contact allergies

Yes

No

MEDICAL HISTORY

List any chronic medical conditions and age of diagnoses

Any hospitalizations in the past? When and for what condition?

Have you ever had allergy testing before? Which method? When? Results?

Have you been on allergy shots before? When? How long?

SURGICAL HISTORY

List any past and planned future surgeries and respective dates

FAMILY HISTORY

(List below any first-degree family members with environmental allergies, asthma, eczema, food allergies, drug allergies, insect sting allergies, contact dermatitis, hives, angioedema/swelling, immune deficiency diseases, or any other chronic medical conditions. Please specify which family members have which conditions below)

Family Member

Diagnoses

Family Member

Diagnoses

Family Member

Diagnoses

Family Member

Diagnoses

Family Member

Diagnoses

CURRENT ENVIRONMENT

Animals in the home (type of animal(s), age(s), and areas of home allowed)

Type of home

Type of floors in the home

Type of heating and A/C

Any problems with mold, damage, or renovations in the home

Smokers in the household

Personal smoking history (if relevant)

Occupation (if relevant)

Grade and name of school

What city do you live in now?

What cities have you lived in before?

CURRENT MEDICATIONS

Name

Frequency

Dose

Name

Frequency

Dose

Name

Frequency

Dose

Name

Frequency

Dose

Name

Frequency

Dose

Name

Frequency

Dose

REVIEW OF SYMPTOMS

Please indicate by checking "yes" or "no" if you have had any significant problems in the areas below.

Recent weight loss or gain

Yes

No

Comment / approximate date

Headaches

Yes

No

Comment / approximate date

Vision or hearing trouble

Yes

No

Comment / approximate date

Thyroid problems

Yes

No

Comment / approximate date

Diabetes

Yes

No

Comment / approximate date

Anemia or abnormal bleeding

Yes

No

Comment / approximate date

High or low blood pressure

Yes

No

Comment / approximate date

Recurrent sinus or ear infections

Yes

No

Comment / approximate date

Recurrent pneumonias

Yes

No

Comment / approximate date

Chest pain

Yes

No

Comment / approximate date

Shortness of breath, cough, wheezing, chest tightness

Yes

No

Comment / approximate date

Liver, gallbladder disease, jaundice

Yes

No

Comment / approximate date

Stomach (ulcer, indigestion, constipation, diarrhea, change in bowel movements)

Yes

No

Comment / approximate date

Abdominal pain

Yes

No

Comment / approximate date

Urinary/kidney/bladder problems

Yes

No

Comment / approximate date

Joint pain or stiffness

Yes

No

Comment / approximate date

Depression/anxiety

Yes

No

Comment / approximate date

Fainting

Yes

No

Comment / approximate date

Strokes or seizures

Yes

No

Comment / approximate date

Pain in other areas

Yes

No

Comment / approximate date

Skin rashes

Yes

No

Comment / approximate date

Other

Yes

No

Comment / approximate date

Δ

Dr. David Jeong MD, board-certified allergist and immunologist at Spring Valley Pediatrics Washington DC

Learn More About Allergy & Immunology

Allergy & Immunology Conditions We Treat Allergy Testing Allergy Treatments Food Allergy Care Center Contact

Link to: Contact Spring Valley Pediatrics

Now Scheduling Allergy & Immunology Appointments

202.966.0815

Spring Valley Pediatrics

4850 Massachusetts Ave, NW

2nd Floor

Washington, DC 20016

Monday – Friday
9:00am to 5:00pm

Saturdays, Sundays, and Holidays:
Sick visits available

For Medical Emergencies Please Call 911

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