610-363-0907
dreffat@chestercountyallergy.com
108 John Robert Thomas Dr. Exton, PA 19341
About
Appointments
Appointment Policy
New Patients
Established Patients
Payment Policy
Forms
New Patient Forms
Established Patient Forms
Prescriptions Request Form
Allergy Education
Allergy Education
Singulair Updates
Directions
Established Patient History
Date of your appointment
*
Time
:
HH
MM
AM
PM
Please enter the first two letters of patient first name
*
Please enter the first two letters of patient last name
*
Date of Birth
*
MM
DD
YYYY
Please describe the main reason that prompted you to seek this consultation:
*
PLEASE CHECK THE BOXES AND COMPLETE THE BLANKS, WHICH APPLY TO YOUR SYMPTOMS, EITHER CURRENTLY OR IN THE RECENT PAST
Eyes
Itching
No
Yes
Tearing
No
Yes
Redness.
Burning.
Swelling.
Dryness.
Blurring.
Comments
Nose and Sinus Symptoms
Sneezing
No
Yes
Itching
No
Yes
Blockage
No
Yes
Nasal secretions
No
Yes
Type of secretions
thin and transparent
thick but transparent
thick and yellow
thick and green
thick and dark
Snoring
Impaired Smell/Taste.
Sinus Infections
Nasal Polyps
Comments
Throat
Sore Throat
No
Yes
Hoarseness
Post Nasal Drainage
What is the drainage like?
No discharge
thin and transparent
thick but transparent
thick and yellow
thick and green
thick and dark
Select type of discharge
Comments
Ears
Earache
No
Yes
Itch
Pressure/Popping
Decreased Hearing
Ear discharge
Ear infections
Comments
Headache
Headache
No
Yes
Select locations of headache
around the eyes
above the eyes
in the temples area
in the back of the head
right side
left side
all over head
Severity?
Mild
Moderate
Severe
Nausea
Vomiting
Blurry vision
Dark spots
Sparks or flashes
Tingling on the face
Sensitivity to light
Comments
Chest
Coughing
No
Yes
Wheezing
No
Yes
Chest tightness
No
Yes
Shortness of breath
No
Yes
Difficulty breathing
Chest pain
Chest phlegm
Select type of phlegm
thin and transparent
thick but transparent
thick and yellow
thick and green
thick and dark
Chest symptoms are
Mild
Moderate
Severe
Select pattern of chest symptoms
Current
Intermittent
Chronic
When do you experience these symptoms?
With Colds
With Exercise
At Sleep
When Wakes Up
How often do your chest symptoms occur?
*
Chest symptoms occur less than once a year
Chest symptoms occur once a year
Chest symptoms occur 2 times a year
Chest symptoms occur 3 times a year
Chest symptoms occur 4 times a year
Chest symptoms occur every other month
Chest symptoms occur once a month
Chest symptoms occur twice a month
Chest symptoms occur thrice a month
Chest symptoms occur once a week
Chest symptoms occur twice a week
Chest symptoms occur thrice a week
Chest symptoms occur once a day
Chest symptoms occur twice a day
Chest symptoms are continuous
Do you use rescue inhalers?
Please Select
Yes
No
( Albuterol, Proventil, Ventolin, Xopenex)
How often?
Once a year
Couple of times a year
once a month
2-3 times a month
once a week
twice a week
every other day
once a day
twice a day
three to four times a day
more than four times a day
Do you use a nebulizer?
Please Select
Yes
No
How often?
less than once a month
once a month
2-3 times a month
once a week
twice a week
every other day
once a day
twice a day
three to four times a day
more than four times a day
If you were ever diagnosed or told that you have asthma, please fill the following questionnaire:
Asthma Control Questionnaire
During the past 4 weeks
How much of the time did your asthma keep you from getting as much done as normal at work at school or at home?
Please select
All the time
Most of the time
Some of the time
A little of the time
None of the time
How often did you have shortness of breath?
Please select
All the time
Most of the time
Some of the time
A little of the time
None of the time
How often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or chest pain) wake you up at night, or earlier than usual in the morning?
All the time
Most of the time
Some of the time
A little of the time
None of the time
How often did you use a rescue inhaler or nebulizer medications (such as albuterol or Xopenex)?
Please select
All the time
Most of the time
Some of the time
A little of the time
None of the time
How would you rate your asthma control?
Please select
Not controlled at all
Poorly controlled
Somewhat controlled
Well controlled
Completely controlled
SMOKING
Did you ever smoke?
*
Select
No
Yes
What did you smoke?
Cigarettes
Cigars
Pipe
Other
How many a day?
Select
1-5
6-10 a day
1 Pack
1 - 2 Packs
2-3 Packs
More than 3 Packs
When did you start smoking?
Did you quit smoking?
Select
No
Yes
When did you quit smoking?
Did you grow up with smoking parents?
*
Select
No
Yes
GENERAL SYMPTOMS PATTERN
When did your current symptoms start this time?
*
Please enter a number
*
Select(Days/Weeks/Months/Years)
Days ago
Weeks ago
Months ago
Years ago
Did you ever have similar symptoms in the past?
*
Select
No
Yes
When was the very first time?
Please enter a number
Select(Days/Weeks/Months/Years)
Days ago
Weeks ago
Months ago
Years ago
Symptoms have been
Sudden
Gradual
Intermittent
Frequent
Continuous
Mild
Moderate
Severe
Worsening
Improving
Unchanged
DO YOUR SYMPTOMS AFFECT THE QUALITY OF YOUR LIFE?
Select
No
Yes
Symptoms adversely affect
Sleep
Activity
Exercise
School
Work
The quality of life in General
WHAT TIME OF THE YEAR ARE YOUR SYMPTOMS NOTICEABLE?
Seasonal
Spring (March-April-May)
Summer (June-July-August)
Autumn (Sept-Oct-Nov)
Winter (Dec-Jan-Feb)
All Year Round
Symptoms are random, no Clear Seasonal Pattern
FACTORS THAT TRIGGER OR AGGRAVATE YOUR SYMPTOMS
Outdoors
Fresh cut grass
House dust
Hay rides
Cat
Dog
Birds
Other Animals
Exercise
Laughter/Crying
Emotional Upset
Menstrual Cycles
Pregnancy
Aerosol/Fumes/Perfumes
Smoke
Cold Air
Air Conditioning
Weather Changes
Dampness
Food
Other
Which food?
What else triggers your symptoms?
HOW WOULD YOU GRADE YOUR SYMPTOMS IN GENERAL?
1
2
3
4
5
6
7
8
9
10
Least : 1 Worst : 10
HOW MUCH DO YOUR SYMPTOMS AFFECT THE QUALITY OF YOUR LIFE?
1
2
3
4
5
6
7
8
9
10
Least : 1 Worst : 10
OTHER MEDICAL CONDITIONS
Has there been any change in your medical or surgical condition since the last visit?
No
Yes
Please list any change in your health history
Has there been any change in the family history?
No
Yes
Please list any change in the family history
Has there been any change in the living or work environment?
No
Yes
Please list any change in the living or work environment
Since your last visit has there been any changes in your medications?
No
Yes
Please refer to the instruction sheet from your last visit Include over the counter, vitamins, herbals and dietary supplements.
Please list any changes in the medication
CURRENT MEDICATIONS
(Include over the counter, vitamins, herbals and dietary supplements.)
Name and Dose
Name and Dosage
Since your last visit have you had any adverse reactions to any medications?
No
Yes
ADVERSE REACTION TO MEDICATIONS
(Include over the counter, vitamins, herbals and dietary supplements.)
Date
Name
Describe Reaction
Home
About Dr. Effat
Appointment Policy
Established Patient Form
New Patient Registration and History Forms
Office Location
Payment Policy
Prescriptions
Allergy Education
Singulair Updates
610-363-0907
dreffat@chestercountyallergy.com
108 John Robert Thomas Dr. Exton, PA 19341
