ABC Pediatrics Allergy Questionnaire

ABC Pediatrics' Allergy Questionnaire

This form must be filled out for new allergy referral patients.
Patient Name

First NameLast Name
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Which provider at ABC do you normally request or see?
Does the patient suffer from allergies?

YesNo
Does the patient take allergy medications?

YesNo
In the last year, check any of the medications that the patient has taken.

BenadrylNasal SpraysVisineClaritinSkin CreamsXyzalInhalerSteroidsZyrtec
When the patient suffers from allergy symptoms, how is his/her quality of life affected? (Check all that apply)

Feels excessively tiredHas medication side effectsHas runny, sore or stuffy noseExperiences watery eyesExperiences headaches/migrainesSuffers Itchy ears, throat, eyes, nose and/or skinSuffers frequent sneezing, sinus infections, asthma flare ups and/or coldsHas decreased senses (smell, hearing or taste)Feels foggy headedIs less attentive at schoolLowers participation in sports
Has the patient ever had a severe anaphylactic reaction (severe allergic reaction) that required emergency medical attention?

YesNo
If YES, Please describe what happened:
Has the patient ever been diagnosed as a moderate or severe asthmatic?

YesNo
Is the patient taking blood pressure medications?

YesNo
Within the past year, has the patient had an allergy scratch test?

YesNo
Within the past year, has the patient had immunotherapy medication prepared?

YesNo
Does the patient have a history of taking allergy medications, including allergy shots?

YesNo
If yes, please list:
Are you interested in learning more about proceeding with allergy testing?

YesNoMaybe
If you answered yes or maybe, please be expecting a call from us soon!
Parent/Guardian Signature
Do not fill anything else out past this point! The information below is for ABC Pediatrics and your provider's use only.
As the patient’s PCP, I am recommending that my patient proceed with Percutaneous (Skin Prick) Allergy Testing. * In Office Use Only

YesNo
Primary Care Provider’s Signature- *In Office Use Only
Should be Empty:

ABC Pediatrics' Allergy Questionnaire