Patient Encounter Form Page 2
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2
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4Patient’s Name
During What Months do Symptoms Occur?
All Months
January
April
July
October
February
May
August
November
March
June
September
December
Are Symptoms Worse?
Morning
Afternoon
Night
At Home
At Work (School)
Other Location
Constant
Erratic
Rare
Not at All
A Little
Moderately
All The Time
Family History:
Asthma
Eczema
Sinus Problems
Migraine
Hay fever
Ulcer
Colitis
Other:
Your Medical Condition?
High Blood Pressure
Heart Disease
Asthma
Emphysema
Stomach/Intestinal Problems
Bronchitis
Thyroid Disease
Diabetes
Hormonal Difficulty
Bee Sting Allergy
DRUG ALLERGY?
List
FOOD ALLERGY?
List
Do any of the following cause or make your symptoms worse?
Milk or Milk Products
Fruit or Juices
Vegetables
Eggs or Egg Products
Beer
Wine
Wheat Products
Liquors
Nuts, Beans, Seeds
Cheese
Mushrooms
Chocolate
Vinegar
Fish
Meat
Poultry
Other
Are your symptoms made worse by?
Wind
Smoke
Barns / Hay
High Pollution Day
Damp Areas
Soap
Powder
Mowing Lawns
Insecticides
Dust
Cats
Dogs
Other Animals
Paint Fumes
Perfumes
Cosmetics
Newspapers
Wool
House Plants
Weather Change
Wet Weather
Dry Weather
Hot Day
Cold Day
Air Conditioning
Travel / Vacations
Indoors (Explain)
Outdoors (Explain)
Have you ever been treated with Allergy
YES
NO
Shots?
If Yes, What were you treated for?
Grass Pollens
Weed Pollens
Tree Pollens
Molds
Dust
Animals
Did the allergy shots help you?
Don’t Know
YES
NO
What years were the shots taken?
Where and when were you treated?
Patient Encounter Form-AW
page 2 of 11
9/17/2013
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