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112 Medical Drive, Palestine, TX 75801

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- Dr. Eric Hensen, DO
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Patient Portal
Before & After
(903) 729-0444
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Allergy Testing Questionnaire

Email

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Patient First Name

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Patient Last Name

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Date of Birth

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Local Pharmacy

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Have you been Allergy Tested before?

Yes

No

Please select an option.

If yes, when:

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where:

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Did you take treatment?

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Why are you needing Allergy Testing?

Wheezing

Please mark this checkbox.

Sneezing

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Loss of Smell

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Loss of Voice

Please mark this checkbox.

Runny Nose

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Hearing Loss

Please mark this checkbox.

Shortness of Breath

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Congestion

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Post-Nasal Drainage

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Headaches

Please mark this checkbox.

Frequent Clearing of Throat

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Bad Breath

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Eczema

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Fatigue

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Other

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Are your allergy symptoms year-round or seasonal?

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Do your symptoms flare up often?

Yes

No

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How long do your flare ups usually last?

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Are your symptoms worse during a certain time of day?

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Are your symptoms worse during certain seasons?

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Are you diagnosed with Upper Respiratory Infections more than 3 times per year?

Yes

No

Please select an option.

Do you have pets?

Please select an option.

If yes, what kind?

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How long have you lived in this area?

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How long have you lived at your current residence?

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Did you have your current allergy symptoms at your previous residence?

Yes

No

Please select an option.

Do you have a Family History of Asthma?

Yes

No

Please select an option.

Have you been diagnosed with Asthma?

Yes

No

Please select an option.

If yes, at what age?

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Have you taken/used any of the following medications within the last week?

Antihistamine/Allergy Medication

Please mark this checkbox.

Blood Pressure Medication

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Nose Spray

Please mark this checkbox.

Blood Thinner

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Sleep Aid/Tylenol PM, Etc

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Inhalers

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Cough Syrup/Drops

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Motion Sickness Medication

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Eye Drops

Please mark this checkbox.

Decongestants

Please mark this checkbox.

Antidepressant

Please mark this checkbox.

Antacids

Please mark this checkbox.

Have you had an Allergic Reaction that caused any of the following:

Hives

Please mark this checkbox.

Swelling of the Throat

Please mark this checkbox.

Difficulty Breathing

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Swelling of the Face

Please mark this checkbox.

What caused the reaction circled above?

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Have you ever been Food Allergy Tested?

Yes

No

Please select an option.

If no, would you like to be tested today?

Yes

No

Please select an option.

If treatment is necessary which option do you feel like you would prefer? (Shots are weekly / Drops are monthly)

Shots

Drops

Please select an option.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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112 Medical Drive, Palestine, Texas 75801

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