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Allergy Intake Form

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emmastenstrom4226
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5 views

Allergy Intake Form

Uploaded by

emmastenstrom4226
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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RAPID ACCESS SPECIALIST CLINIC

PHONE: 604-806-8735 #2
FAX: 604-806-9057
ROOM 5900, BURRARD BUILDING-5TH FLOOR
ST. PAUL’S HOSPITAL, 1081 BURRARD ST
Allergy Intake Form

Name: _________________________ Date:_______________

Please describe reason for visit:

Current Medications (including vitamins, naturopathic remedies, over the counter


medications)

Medical history:

Past Surgeries:
______
Family history (allergies, autoimmune conditions, malignancy)
HISTORY OF:
Malignancy Yes No
Hives Yes No Seasonal/nasal allergies Yes No
Asthma Yes No Recurrent infections Yes No
Eczema Yes No Intermittent swelling Yes No
Food allergies Yes No Autoimmune disease Yes No
Insect Anaphylaxis Yes No Drug allergies Yes No

Environmental History:
Occupation: ____
Do you smoke? __ If so, how many cigarettes per day?
Average alcohol intake per week:
Marijuana use? Yes □ No □
What type of housing: house/duplex/townhouse/apartment/basement?
What type of heating/cooling system do you have in your home?
Forced air/ Radiator/ Baseboard heat/ Central air/ Wood burning heat
Is there any obvious mould or previous water damage? Yes □ No □
Do you have family pets? Yes □ No □
Is there wall to wall carpeting Yes □ No □
Does anyone smoke in your household? Yes □ No □
Do you have extended health benefits? Yes □ No □

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