ALLERGY AND ASTHMA CENTER OF SOUTHWEST ARLINGTON
Name:_________________________ Age:_______________ Date of Birth:__________
Please circle symptoms that apply at some point during the year
NOSE
Runny Blocked
Stuffy Sneezing
Loss of smell Itchy
EYES
Watery Itchy
Puffy lids Red
Dark circles
EARS
Popping Blocked
Hearing loss Itchy
Frequent Infection
THROAT
Sore Itchy
Drainage
CHEST
Wheeze Cough
Phlegm Pain
Tightness
Shortness of breath
OTHERS
Skin rash Nausea
Headache Fatigue
Abdominal pain
WORST SEASON
Spring Summer
Fall Winter
All year
CURRENT MEDICATIONS
DRUG ALLERGIES
PETS AT YOUR HOME
Cat Horse
Other_________ Dog
ANY ALLERGY OR ASTHMA
IN YOUR FAMILY? Y N
WHO?
Father Mother Sibling Children
Are immunizations current? Y N