Allergy & Asthma Center, P.C.
Candice M. Rohr, M.D. Alice H. Chou, M.D. Alalia W. Berry, M.D.
330 S. Garden Way #150, Eugene, OR 97401 ~ Phone 541-485-0316 ~ Fax 541-431-0317
330-C NW Elks Drive, Corvallis, OR 97330 ~ Phone 541-754-7170 ~ Fax 541-758-0707
Patient Name
Date of Birth Date
Briefly describe reason for allergy visit:__________________________________________________________________
Have you ever had the following conditions? (Write YES or NO for each item):
Age at
1-2 days/week
2-5 days/week
5+ days/week
Runny nose or itchy nose
Itchy eyes
Stuffy or congested nose
Sinus problems
Persistent coughing
Chest tightness
Shortness of breath
Bronchitis or prolonged coughing
with “colds”
Emergency room visit or
hospitalization for breathing
Check any symptoms that occur after vigorous exertion or exercise:
coughing wheezing chest tightness throat clearing
Are your symptoms worse during certain months of the year?
Yes No
Which months?______________________________________________________________________________
If yes, do you have mild symptoms year around?
Yes No, am well rest of the year
Check any conditions that make your symptoms worse:
mowing the lawn, exposure to cut grass, playing in grass raking leaves
sweeping, dusting, using vacuum cleaner being around animals or the places where animals live
tobacco smoke or other fumes strong odors or perfumes
moldy or mildewed areas other (specify below)
BEE STING (honey bee, yellow jacket, hornet, wasp):
Date of sting(s)______________________________________________________________________________
I had the following reaction:
large local swelling around the sting only trouble breathing
hives or swelling on other parts of my body vomiting feeling faint
I have had reactions to the following food(s):
milk eggs fish peanut nuts
other (specify)____________________________________________________________________________
I get the following symptoms from these foods:
stomachache loose bowels (diarrhea) nausea
rash stuffy nose asthma other (specify)__________________________________________
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Patient’s Name_______________________________________________Birthdate____/____/____
Geographic history:
Where were you born?________________________________________________________________________
In what state (country) did you spend most of your life?_____________________________________________
How long have you lived in Oregon?_____________________________________________________________
Home environment:
Type of heating:______________________________________________________________________________
How old is your mattress?__________________pillow?_______________check if waterbed________________
Yes No Is your pillow covered with zip-on hypoallergenic covers? Yes No Synthetic
Yes No Do you have a feather comforter?
Yes No Is there carpeting in your bedroom? How old is it?_____________
Yes No Does your house have dampness, mold, or mildew problems?
How old is your home?____________ How long have you lived there?____________
Is it an apartment?____________ Is it a manufactured home?____________
How many pets come inside your home (specify number)?
__________dogs __________cats __________other (specify) _______________________________
Yes No Do you have horses or other outside animals?
Lifestyle history:
Yes No Have you ever smoked or vaped? Date quit____________________________________________
Yes No Do you presently smoke or vaped?
How many
years have you or did you smoke or vape? _________________________________________
How many packs (average) per day?_____________________________________________________________
No Does anyone else in the home smok
e or vape? Who?
Yes No Do you use alcohol? How much/how often?_________________________________________
Yes No Do you use recreational drugs? What?______________________________________________
Yes No Do you have an Advance Directive?
Occupational history:
What type of work do you do?_________________________________________________________________
Do you use over-the-counter nose sprays? Yes No Occasionally Regularly
Have you ever received a corticosteroid (cortisone) injection for allergies?
Yes No
Have you had sinus surgery?
Yes No Date______________________________________________
Date of last chest x-ray:________________________ Date of last sinus CAT scan:___________________
Review of Systems: Have you ever had any of the fol
lowing? Circle or check all that apply:
Frequent headaches High blood pressure Stomach or digestive problems
Ear infections/Sinus infections Thyroid problems Kidney trouble
Glaucoma/Cataracts Skin problems Liver trouble
Heart trouble
Tuberculosis Neurological problems
Family Health:
Yes No Is there a history of allergy in your family? If yes, please indicate:
Allergies Hay feve
Asthma Sinus problems Eczema Hives
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