325 Tamarack Lane Shiloh, IL 62269 (618) 624-2060

325 Tamarack Lane
Shiloh, IL 62269
(618) 624-2060
Fax (618) 624-2226
www.aaicenter.org
Name: __________________________________________________________________________
Last
First
Middle
Age: ____________________
Height: ______________
Date of Birth ___________________________
Weight: ___________
Address: ________________________________________________________________________
________________________________________________________________________________
Telephone: Home (
) _______________________
Were you referred by a physician?
_____ Yes
Work (
) _____________________
_____ No
If yes, please provide us with the name, address and phone number of the physician referring you:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Who is your primary care physician? (Name, address and phone number)
Would you like us to send a letter to your primary care physician regarding your visit with us? _____ Yes
_____ No
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
If there are other physicians whom you wish to receive copies of our evaluation, please list the
names, addresses and phone numbers of these physicians below:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
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HISTORY OF PRESENT ILLNESS
Rash / Eczema / Hives (Urticaria) / Swelling (Angioedema)
a) I think I have:
___ eczema
___ hives (urticaria)
___ rashes or other skin problems
___ swelling (angioedema)
b) How long has this problem been going on? _______________________________________________
c) What was your first episode of symptoms like? (you may describe other episodes below as well)
__________________________________________________________________________________
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d) What events preceded the symptoms?___________________________________________________
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e) Description:
Color: _____ red
_____ other (please describe: ______________________________________)
Number of lesions (areas of rash): ______________________________________________________
Typical size of lesions: _______________________________________________________________
Associated descriptors:
_____ skin/rash is flat.
_____ skin/rash is raised above surrounding, unaffected skin.
_____ skin/rash has a well defined border.
_____ skin/rash has a poorly defined border.
_____ skin/rash blanches (loses color) with pressure (touch).
_____ skin/rash color is unaffected by pressure (touch).
_____ skin/rash develops/worsens after I rub my skin (e.g. appears if I stroke my skin)
(please describe: _______________________________________________________)
_____ skin/rash has other distinctive characteristics (e.g. scaling/flaking)
(please describe: _______________________________________________________)
f)
What provokes (worsens the rash)? (+ = usual/often; s = sometimes; n = never)
___ alcohol
___ animal exposure (cat, dog, dust mite) (please explain: _____________________________)
___ bath
___ environment (please explain: ________________________________________________)
___ exercise
___ food (please explain: _______________________________________________________)
___ menstrual periods
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___ stress
___ shower
___ temperature change (please explain: __________________________________________)
___ tight-fitting clothes (bra, underwear lines)
___ topical agents (lotions, creams, make-up) (please explain: _________________________)
___ other (please explain: ______________________________________________________)
g) Do any of the following physical stimuli initiate or worsen your rash?
___ cold (ice cube, cold water, cold wind, or weather)
___ exercise
___ heat
___ increased body temperature
___ insect bites
___ pressure
___ sun exposure
___ sweating
___ vibration
___ other (Please explain: ______________________________________________________)
h) What improves the rash? (+ = usual/often; s = sometimes; n = never)
___ bath
___ medications (please explain: _________________________________________________)
___ shower
___ temperature change (please explain: __________________________________________)
___ other (please explain) ______________________________________________________)
i)
Symptoms:
___ itching
___ burning
___ pain
___ other (please describe: _____________________________________________________)
Associated symptoms (+ = usual/often; s = sometimes; n = never)
___ cough
___ fever
___ flu-like feeling (weakness, run-down)
___ hoarseness
___ itch eyes/ears
___ joint paint
___ nasal congestion
___ nausea
___ shortness of breath
___ cramping/diarrhea
___ throat swelling ___ vomiting
___ wheezing
___ other (please explain) _______________________________
j)
Body parts involved:
___ arm(s)
___ legs
___ scalp
(+ = usual/often; s = sometimes; n = never):
___ back
___ lip(s)
___ tongue
___ eyelid(s)
___ neck
___ face
___ front of trunk
___ palms of hands
k) What time(s) of day does the rash occur:
___ any time (no predilection)
___ 6 am – noon
___ noon – 6 PM
___ 6 PM – bedtime
___ during the night
l)
How often do you usually have the rash?
___ several times a day
___ several times a week
___ monthly
___ seasonal
___ daily
___ weekly
___ any relation to menses
___ other (please explain) ___________________
m) How long does the rash last (if you have multiple areas of involvement, this question refers to ONE spot
or area of the rash, not the rash as a whole)?
___ minutes
___ few hours
___ 24 -72 hours
___ >3 days
3
n) How long does the rash (as a whole) last?
___ minutes
___ hours
___ 24 – 72 hours
___ days
o) Is there a time of year when your rash worsens? ___ Yes ___ No (If yes, please indicate the worse
season(s))
___ Spring ___ Summer ___ Fall ___ Winter
p) Have you been away from home since your symptoms began? ___ Yes ___ No
Please list trips (more than 3 days) by location and duration.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Did symptoms change during or after these trips? ___ Yes ___ No
If yes, please explain: ___________________________________________________________________
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q) Do you notice a pattern to your rash not otherwise described above? ___ Yes
___ No (If yes, please
describe: _________________________________________________________________________)
r) What are your thoughts about what may be causing your problem? What are your major concerns? If
you think it may be helpful, please describe individual episodes below or on a separate page.
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PAST EVALUATIONS
What previous evaluation have you had for this problem?
Other physician evaluation (if yes, please describe evaluation, findings and procedures): ___________
__________________________________________________________________________________
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Skin test, blood tests, biopsies: ________________________________________________________
__________________________________________________________________________________
Other: ____________________________________________________________________________
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MEDICATIONS
Please list all the medications that you are now taking.
Medication Name
Number of times per day
medication is taken
Dose
4
Taken
Since
a) Are you allergic to any medications? ___ Yes ___ No (If yes, please describe the drug(s),
reaction(s) and approximate year of the incident(s):_________________________________________
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b) When was your last dose of an antihistamine (e.g. Zyrtec, Allegra, Claritin, Benadryl)? _____________
c) Did this/these medication(s) improve the rash? ____ Yes
____ No
Please circle any of the medicines above that you were taking when your symptoms began.
Please list all other prescription and over-the-counter medicines that you were taking when your problem
started. _________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
d) Do/did you EVER take any of the following medications (If yes, please describe):
Aspirin (Bufferin, Excedrin, etc.): __________________________________________________
Blood Pressure Medications (ACE-inhibitors, ARBs, etc.): ______________________________
“Non-steroidal anti-inflammatory drugs (AKA NSAID, e.g. ibuprofen or Motrin): ______________
____________________________________________________________________________
Oral contraceptive (birth control pills): ______________________________________________
Tylenol: _____________________________________________________________________
Vitamins or supplements: _______________________________________________________
Oral contraceptives (birth control pills): _____________________________________________
PAST ALLERGY HISTORY
Have you ever had: (check all that apply)
___ allergic rhinitis (hay fever)
___ sinus problems
___ asthma
___ atopic dermatitis (eczema)
___ other allergy (please describe: __________________
______________________________________________)
Have you undergone allergy skin testing? ___ Yes ___ No
If yes, please provide the name of the physician and date(s) of these test(s):
____________________________________________________________________________
Have you received allergy shots? ___ Yes ___ No
If yes, when did you receive them, and for how long? _________________________________
Do you feel the allergy shots were beneficial? ___ Yes ___ No
If yes, please explain: __________________________________________________________
Do you have any proven or suspected food allergies? ___ Yes ___ No
If yes, please explain: __________________________________________________________
Do you have any other allergy problems such as “bee” sting reactions or eczema? ___ Yes ___ No
If yes, please explain: __________________________________________________________
Have you ever had any form of “contact” dermatitis?
___ additives including fragrance, dye, preservative
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___ creams or lotions
___ detergents
___ jewelry, nickel or other metals
___ latex or rubber
___ poison ivy, oak or sumac
If yes, please describe reaction: __________________________________________________
PAST MEDICAL HISTORY
Please list current and past medical problems (i.e. diabetes, heart disease, cancer, etc.).
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Have you ever been experienced or been diagnosed with?
___ arthritis
___ blood in stool
___ blood in urine
___ blood transfusions
___ deafness
___ fatigue
___ flushing
___ hepatitis
___ limb pain
___ lupus (or other autoimmune disease)
___ thyroid problems
___ unintentional weight loss
___ yeast/fungal infection
___ other chronic illness not listed above (if yes, please explain): ______________________________
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PAST SURGICAL HISTORY
Please list all surgical procedures you’ve had done, and indicate the approximate year of the surgery.
approximate
date of surgery
surgical procedure
__________________________________________________________________________________
__________________________________________________________________________________
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HOSPITALIZATIONS
Have you ever been hospitalized? ___ Yes ___ No
If yes, please provide the following information:
date of
admission
length of
hospitalization
diagnosis or reason
for hospitalization
____________________________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
INFECTIONS
Do you have frequent infections (i.e. pneumonia, bronchitis, sinusitis, ear infections, etc.)?
___ Yes ___ No If yes, please provide the following information:
approximate
date of infection
infection site
__________________________________________________________________________________
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Did you have symptoms of asthma as a child? ___ Yes ___ No
Did you have frequent respiratory infections as a child? ___ Yes ___ No
Did you have exposure to passive cigarette smoke in infancy? ___ Yes ___ No
VACCINATIONS
Date of last flu shot. ________________
SOCIAL AND OCCUPATIONAL HISTORY
Marital status: ___married ___ single
Date of pneumococcal vaccine: _____________________
___ widowed
___ divorced
___ separated
Please list number of children _____ ages: __________
Do any of your children have any chronic illnesses? If yes, please explain: ______________________
__________________________________________________________________________________
Do you ever drink alcoholic beverages? ___ Yes ___ No
If yes, what is your drink of choice? _______________________________________________
Number of drinks per day? ______________________________________________________
Have you ever used recreational drugs? ___ Yes ___ No
If so, what drugs? _____________________________________________________________
Have you ever smoked tobacco? ___ Yes ___ No
If yes:
Are you still smoking? ___ Yes ___ No
How old were you when you started smoking? _____
How old were you when you quit smoking? _____
How many packs per day did you average? _____
Are you currently employed? ___ Yes ___ No
If yes:
How many hours per week do you work? _____
What is your current occupation? _________________________________________________
How long have you worked in this occupation? _____
List chemical/exposures that you encounter at work: ________________________________________
__________________________________________________________________________________
Do you believe that your current or previous occupation has any bearing on your illness? __Yes __No
If yes, please explain: __________________________________________________________
____________________________________________________________________________
How much work or school have you missed due to your breathing difficulty within the past year?
__________________________________________________________________________________
Please describe the effect of your illness on your job or school performance. ____________________
__________________________________________________________________________________
Do you have any pending or planned legal action against your current or former employer which
pertains to your medical illness? ___ Yes ___ No
Do you anticipate that your evaluation will be used in any legal action against your current employer or
former employer? ___ Yes ___ No
Have you ever worked in a factory, textile mill, farming, grain mill, shipyard or in a mine?
___ Yes ___ No If yes, please explain. ______________________________________________
__________________________________________________________________________________
Have you had any job with high exposure to fumes, chemicals, dust or other noxious substances?
___ Yes ___ No If yes, please explain. ______________________________________________
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What kind(s) of exercise do you perform regularly? _________________________________________
__________________________________________________________________________________
How often do you perform this exercise? _________________________________________________
What, if any, hobbies or leisure activities do you engage in? __________________________________
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ENVIRONMENTAL AND DIET HISTORY
Please describe your current living situation (private home, apartment, living with relatives, etc.)?
__________________________________________________________________________________
Where is the home located (i.e. rural, city, near any major factories or industries, etc.)?
__________________________________________________________________________________
Age of home: ______________
How long have you lived there? __________________________
How many people live in the home? ____________________________________________________
Home Description
Yes
No
Further description if necessary
Basement?
___
___
___________________________________
Any water damage in basement?
___
___
___________________________________
Smokers in the home?
___
___
___________________________________
Air conditioning? Central air?
___
___
___________________________________
Forced air heating? Gas or electric?
___
___
___________________________________
Fireplace? Used how often?
___
___
___________________________________
Wood burning stove? Used how often?
___
___
___________________________________
Do you vacuum the home?
___
___
___________________________________
Air purification systems?
___
___
___________________________________
Pillow and mattress dust-proof encasings? ___
___
___________________________________
Do you use a humidifier?
___
___
___________________________________
Is the humidifier cleaned regularly?
___
___
___________________________________
Pets? What kind? How many?
___
___
___________________________________
Where do your pets sleep?
_______________________________________________
Fabric softeners used?
___
___
___________________________________
Plants in the home? How many?
___
___
___________________________________
Where are they kept?
_______________________________________________
Is there carpeting in your bedroom?
___
___
___________________________________
Do you have wall-to-wall carpeting?
___
___
___________________________________
If yes, what is the age of your carpeting? ___________________________________________
What is the age of your mattress? ______________________________________________________
What kind of pillows do you sleep on (feather, synthetic)? ____________________________________
What is the age of your pillow? ________________________________________________________
What material are your bedding items made of?
Sheets: _____________________________________________________________________
Pillowcases: _________________________________________________________________
Quilts: ______________________________________________________________________
Blankets: ____________________________________________________________________
List brands of products containing chemicals that you use regularly or have recently added to your
personal care routine.
Shampoo: ______________________________________________________________________
Conditioner: ____________________________________________________________________
Soap: _________________________________________________________________________
Laundry Detergent: _______________________________________________________________
Fabric Softener: _________________________________________________________________
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Deodorant: _____________________________________________________________________
Perfume / cologne / after-shave: ____________________________________________________
Air fresheners / other scented products: ______________________________________________
Hair coloring dyes / rinses: _________________________________________________________
Other: _________________________________________________________________________
List all food and drink, including snacks that you have eaten in the past 24 hours:
__________________________________________________________________________________
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Do you regularly consume products with aspartame (Equal® or NutraSweet®)? ___ Yes ___ No
Do you regularly consume products with artificial coloring?
___ Yes ___ No
Have you ever noticed worsening of your rash with these food items?
___ Yes ___ No
FAMILY HISTORY
Does anyone in your immediate family (parents, brothers, sisters and children) have any of the
following illnesses? If yes, tell us who has the illness.
Allergies
___ Yes ___ No
_________________________________________
Angioedema
___ Yes ___ No
_________________________________________
Asthma
___ Yes ___ No
_________________________________________
Autoimmune disease ___ Yes ___ No
_________________________________________
Cancer
___ Yes ___ No
_________________________________________
Cystic Fibrosis
___ Yes ___ No
_________________________________________
Diabetes
___ Yes ___ No
_________________________________________
Eczema
___ Yes ___ No
_________________________________________
Emphysema
___ Yes ___ No
_________________________________________
Heart Disease
___ Yes ___ No
_________________________________________
Hives (urticaria)
___ Yes ___ No
_________________________________________
Other (Please explain: ______________________________________________________________)
REVIEW OF SYSTEMS
Please check any of the following symptoms which you are currently experiencing, or which have
caused you serious problems in the past.
Constitutional:
___ fever
___ night sweats
___ fatigue
___ weight loss
___ severe itching
___ cold intolerance
___ weight gain
___ loss of appetite
___ heat intolerance
Special senses:
___ loss of vision
___ glaucoma
___ ringing in ears
___ dry eyes
___ itchy eyes
___ blurry vision
___ loss of hearing
___ loss of balance
___ excessive tearing
___ conjunctivitis
___ cataracts
___ itching in ears
___ loss of sense of smell
___ loss of sense of taste
___ ear infections
Lymph glands:
___ glandular swelling
Heart:
___ chest pain
___ palpitations
___ inability to lie flat in bed
___ swelling of ankles
Intestinal tract:
___ nausea
___ indigestion
___ diarrhea
___ heartburn
___ constipation
___ gall stones
___ glandular tenderness
___ vomiting
___ abdominal pain
___ excessive gas
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___ food intolerances ___ acid or sour taste in mouth
___ trouble swallowing liquids or foods
Reproductive:
___ irregular periods ___ skipped periods
___ unusual vaginal bleeding
___ menopause
___ infertility
___ miscarriages
___ impotence
Are you pregnant now or planning a future pregnancy? ___ Yes ___ No
Urinary:
___ kidney stones
___ inability to urinate
___ kidney infections
Rheumatologic
& orthopedic:
___ joint swelling
___ joint pain
___ low back pain
___ fractured bones
Skin:
___ skin rash
___ excessive hair loss
Neurological:
___ passing out spells
___ epilepsy (seizures)
___ inability to concentrate
___ prostate problems
___ early morning joint stiffness
___ gout
___ osteoporosis
___ hives
___ skin tumors or growths
___ eczema
___ severe headaches
___ difficulty with memory
Please elaborate on any symptoms which are particularly bothersome to you.
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Physician Signature: ________________________________________________ Date: __________
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