Hives/itching - Dakota Allergy Asthma printable pdf download

INTERNAL USE ONLY

Patient Name _______________________________________

Chart/Account # __________________ DOB _____________

Doctor _____________________________________________

Date _______________________________________________

HIVES/ITCHING

How Long Have You Had Hives/Itching? _______________________________________________________________________________________

How often Do You Get Hive/Itching? o Weekly o Daily o Other _________________________________________________________

How Long Does It Last Once It Comes? _______________________________________________________________________________________

Itching Present Or Not? ________________________________

Do You Have Any Pain Or Burning With Hives? _______________________

How Does It Look To You? ___________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

What Body Parts Are Affected? Is It All Over the Body? Head/Scalp? ______________________________________________________________

___________________________________________________________________________________________________________________________

When It Goes Away, Does It Leave Any Marks Behind? __________________________________________________________________________

Are You Under High Stress? __________________________________________________________________________________________________

Do You Take OTC Pain Killers, Like Ibuprofen, Etc.? How Often? __________________________________________________________________

___________________________________________________________________________________________________________________________

What Medications Have You Tried? Did They Help? _____________________________________________________________________________

___________________________________________________________________________________________________________________________

Did You See A Dermatologist? _______________________________________________________________________________________________

___________________________________________________________________________________________________________________________

Do You Have Exposure To New Contacts, Environments or Medications? __________________________________________________________

___________________________________________________________________________________________________________________________

Do You Have Other Symptoms Like Nausea, Abdominal Pain, Fever, Weight Loss, Etc.? _____________________________________________

___________________________________________________________________________________________________________________________

Do You Get Lip Swelling, Face Swelling, Throat Closing? How Often? _____________________________________________________________

___________________________________________________________________________________________________________________________

How Often Have You Been To the ER? _________________________________________________________________________________________

What Are The Goals Of Your Visit Today? ______________________________________________________________________________________

PLEASE COMPLETE FORM PRIOR TO YOUR APPOINTMENT

605-336-6385

Fax 605-336-6513

Mark E. Bubak, MD | Julie F. Nielsen, PA-C | Lindsey R. Peterson, CNP

2200 West 49th Street, Suite 104, Sioux Falls, SD 57105

Hives/itching - Dakota Allergy Asthma