| Patient's Name |
| Date |
| Onset of symptoms |
| List symptoms in order of severity (ranging form 1-most bothersome, 2,3,4-mild) |
| 1. |
| 2. |
| 3. |
| 4. |
| 1. Are your symptoms worse during any particular season, or are they year round? |
| 2. Are your symptoms worse at any particular time of day? |
| 3. Do you know what triggers your symptoms? |
| 4. Do you take any medications for your symptoms? |
| 5. Does the inside of your nose itch? |
| 6. Do you have sneezing attacks? |
| 7. Does your nose block often? |
| 8. Do you get headaches when your nose blocks? |
| 9. Do you have to blow your nose? Is it watery or thick mucus? |
| 10. Do you have postnasal drip? |
| 11. Is your nasal blockage worse at any time of the day? When? |
| 12. Have you ever been treated for sinus trouble? |
| 13. Have you ever had polyps removed from your nose or sinus? |
| 14. Does your throat or roof of the mouth ever itch? |
| 15. Do you clear your throat frequently? |
| 16. Do you usually have a sore throat in the morning that passes? |
| 17. Do you get ulcers or canker sores in the mouth? |
| 18. Do you cough frequently? Upon rising? At night? |
| 19. Do you have asthma or ever had bronchitis? |
| 20. Do you suffer with eczema or any skin condition? |
| 21. Have you ever had hives? When? What caused it? |
| 22. Do you ever have swelling of the skin for no apparent reason? Eyes, hands, ankles? |
| 23. Are you bothered by itching skin when no rash is present? When? |
| 24. Does contact of your skin with certain substances cause a rash? |
| 25. Do you have frequent headaches? How often? Does medicine help? What kind? |
| 26. Do you feel tired after a good nightâs sleep? |
| 27. Do you have any muscle, back, or joint aches, leg pains? |
| 28. Do your eyes, ears, or feet ever itch/athleteâs foot? |
| 29. Do you ever have ringing in your ears, dizzy spells? |
| 30. Did you have eczema as a child? |
| 31. Did you have colic or feeding problems as a baby? |
| 32. Did you have croup as a child? |
| 33. Have you had any previous ENT surgery? |
| 34. Do you have low or high blood pressure? |
| 35. Is here a family history of allergy? |
| 36. Have you ever had: Measles? |
| Tonsillitis? |
| Pneumonia? |
| Recurrent ear infections? |
| Asthma? |
| Hayfever? |
| Migraines? |
| Mono? |
| 37. Is there a family history of sinus problems, headaches? Skin conditions or asthma? |
| 38. Do you drink alcohol? |
| 39. Do you smoke? |
| 40. Do you use nose sprays? Frequency Type |
| 41. Are your symptoms worse outdoors or indoors? |
| 42. Are your symptoms worse when· You clean the house |
| The heat goes on in the fall |
| After you go to bed a night |
| 43. Are your symptoms worse when· The weather is damp |
| You are around cut grass |
| You are in the basement of an old house |
| You are out in the early evening |
| Early fall or winter begins |
| 44. Do you have any feather or down products? |
| 45. Does smoke bother you? |
| 46. Do you have problems with perfumes, cosmetics, and soaps? |
| 47. Do you have any pets? |
| 48. Do you use wool blankets or have wool carpeting? |
| 49. How old is your house? |
| 50. What type of heating is in your home? Gas Electric Propane |
| 51. Do you use a wood burning stove? |
| 52. Do you have air conditioning or fans? |
| 53. How many houseplants do you have? What rooms do you have houseplants? |
| 54. Do you have carpeting or hard wood floors? Carpeting hardwood both |
| 55. How old is your mattress? |
| 56. Do you do any hobby or work in the home that requires special chemicals or supplies? |
| 57. Describe your work environment |
| 58. Do your symptoms seem better or worse· at work on vacation away from home |
| 59. Are you presently on medications for any other medical problems? |
| 60. Are you on birth control pills? |
| 61. Have you every had allergy testing and/or treatment with injections? |
| 62. Are you allergic to any medications? If so, which |
| 63. Do you have stomach aches, intestinal discomfort, bloating,excess gas, indigestion, constipation or Diarrhea? |
| 64. Do you have frequent yeast infections? |
| 65. Do you have any food allergies? If so, what are they? |