Patient Questionnaires | SRQ Allergy & Asthma

Social & Family History

This form helps us understand your environmental exposures, habits, and family health history relevant to allergy and asthma care.

Fields marked * are required.

Patient Information

First Name *

Last Name *

Date of Birth *

Today's Date

Primary Care Coordination

Who is your Primary Care Provider (PCP)?

Habits & Exposure

Smoking History

Never smoked

Current smoker or vape user

Former smoker

Alcohol Use

Environmental History

Do you have pets at home?

Family Allergic History

Do any parents, siblings, or children have asthma or allergies?

Please review your answers before submitting. Your information will be reviewed by our clinical team prior to your appointment.

Allergic Rhinitis & Sinus Questionnaire

Comprehensive evaluation for nasal allergies, sinus symptoms, and related respiratory concerns.

Fields marked * are required.

Patient Information

First Name *

Last Name *

Date

Date of Birth *

Section 1: Timing & Frequency

1. When do your symptoms typically occur?

Seasonal only (during pollen seasons)

Year-round

Year-round, worse during certain seasons

2. How often do you experience symptoms?

Intermittent — fewer than 4 days a week or only for a few weeks

Persistent — more than 4 days a week and lasting many weeks

Section 2: Symptoms & Respiratory Health

3. Which of the following do you experience? (Check all that apply)

Frequent sneezing

Runny nose (clear/watery)

Nasal congestion (stuffy nose)

Itchy nose, eyes, or throat

Post-nasal drip

Frequent throat clearing

Itchy, watery, or red eyes

Ear congestion, popping, or itching

Frequent headaches or facial pressure

4. Associated respiratory symptoms (asthma screen)

Persistent cough (especially at night or with exercise)

Wheezing or chest tightness

Shortness of breath

Section 3: Environmental & Lifestyle Triggers

5. Do your symptoms worsen around any of the following? (Check all that apply)

At home: bedding, pillows, old carpets, or upholstered furniture

Indoor factors: houseplants, damp areas, or wood-burning stoves

Animals: cats, dogs, or other pets (even if you don't own one)

Outdoors: cut grass, yard work, or specific trees/weeds

Irritants: tobacco smoke, perfumes, or strong cleaning chemicals

Weather: sudden changes in temperature or humidity

Section 4: Impact & Quality of Life

6. Do your symptoms interfere with any of the following?

Sleep: difficulty falling or staying asleep

Daily life: work, school, or sports/hobbies

Mood: feeling irritable or frustrated by symptoms

7. How bothersome are your symptoms today? (0 = not at all, 10 = severe)

Section 5: Previous Testing & Medications

8. Medications tried (check all that apply)

Antihistamines (Zyrtec, Allegra, Claritin, Xyzal, Benadryl)

Nasal steroid sprays (Flonase, Nasacort, Rhinocort, Nasonex)

Nasal antihistamine sprays (Astepro, Azelastine)

Decongestants (Sudafed, Afrin)

Oral steroids (Prednisone, Medrol Dose Pack)

Please review your answers before submitting. Your information will be reviewed by our clinical team prior to your appointment.

Hives & Skin Questionnaire

Please complete this form before your appointment. Your answers help us evaluate your condition more effectively.

Fields marked * are required.

1. Patient Information

First Name *

Last Name *

Date of Birth *

Today's Date

2. About Your Hives / Swelling

Which best describes what you are experiencing? * Select all that apply

Hives (raised, itchy welts on skin)

Angioedema (deep swelling under skin)

Both hives and swelling

Not sure

When did your hives/swelling first start? *

Today

A few days ago

A few weeks ago

More than 6 weeks ago

How often do episodes occur? *

Daily or almost daily

Several times a week

A few times a month

Occasionally / unpredictably

How long does a single episode typically last?

Less than 1 hour

1–24 hours

More than 24 hours

Varies each time

3. Symptoms & Severity

What symptoms accompany your hives/swelling? (Check all that apply)

Itching

Burning or stinging

Pain or tenderness

Throat tightness

Difficulty breathing

Dizziness or lightheadedness

Nausea or stomach pain

No other symptoms

How much do your hives/swelling affect your daily life? * 0 = No impact at all | 10 = Severely impacts daily life

4. Possible Triggers

Do you notice anything that seems to trigger or worsen your hives/swelling? (Check all that apply)

Food or drink

Medications

Insect sting or bite

Skin contact (plants, latex, chemicals)

Heat or sweating

Cold temperatures or water

Exercise

Stress

No known trigger

5. Emergency & Prior Care

Have you ever needed emergency or urgent care for hives/swelling?

Yes

Please describe what happened and how you were treated:

Do you carry an epinephrine auto-injector (EpiPen)?

Yes

Prescribed but not filled

6. Recent Changes & Lifestyle

Have you made any recent changes that may be relevant? (Check all that apply)

Change in diet or new foods

New soap, detergent, or lotion

New pet in the home

New medications or supplements

Recent travel

Increased stress or major life event

No recent changes

Is there anything else you would like your doctor to know?

Please review your answers before submitting. Your information will be reviewed by our clinical team prior to your appointment.

Food Allergy Questionnaire

This form helps us evaluate suspected food allergies or intolerances. Complete it before your appointment so your physician can prepare appropriately.

Fields marked * are required.

1. Patient Information

First Name *

Last Name *

Date of Birth *

Today's Date

2. Suspected Foods

Which of the following foods do you suspect you may be allergic to? * Select all that apply — these are the most common food allergens

Peanuts

Tree nuts (almonds, cashews, walnuts, etc.)

Milk / dairy

Eggs

Wheat / gluten

Soy

Fish (salmon, tuna, cod, etc.)

Shellfish (shrimp, crab, lobster, etc.)

Sesame

Other food (describe below)

If other, please describe the food(s):

3. Reaction History

What symptoms have you experienced after eating the suspected food? * Select all that apply

Hives or skin redness

Swelling of lips, face, or throat

Itching of mouth, skin, or throat

Nausea, vomiting, or stomach cramps

Diarrhea

Difficulty breathing or wheezing

Throat tightness or hoarseness

Dizziness or lightheadedness

Feeling faint or loss of consciousness

Runny nose or watery eyes

How quickly do symptoms typically start after eating the food? *

Within minutes (under 30 min)

Within 1 hour

1–4 hours

Several hours or next day

Not sure

How severe is your worst reaction? *

Mild — localized hives or itching only

Moderate — hives plus GI symptoms or mild swelling

Severe — breathing difficulty, throat tightness, or feeling faint

Anaphylaxis — required epinephrine or emergency care

Does every exposure to this food cause a reaction?

Yes, every time

Most of the time

Sometimes

It has only happened once

4. Emergency & Prior Care

Have you ever required emergency or urgent care for a food reaction?

Yes

Please describe what happened and how you were treated:

Do you carry an epinephrine auto-injector (EpiPen)?

Yes

Prescribed but not filled

5. Current Management

Are you currently avoiding the suspected food?

Yes, strictly avoiding

Partially avoiding

Not avoiding — still eating it

Have you had allergy testing for this food before?

Skin prick test

Blood test (IgE / RAST)

Oral food challenge

No prior testing

Have you or your child outgrown any food allergies in the past?

Yes

Not applicable

6. Family & Additional History

Do any family members have food allergies?

Yes

Please describe (relation and food):

Do you have any of the following conditions? Select all that apply — these can affect food allergy evaluation

Eczema or atopic dermatitis

Asthma

Allergic rhinitis (hay fever)

Eosinophilic esophagitis (EoE)

None of the above

Is there anything else you would like your doctor to know?

Please review your answers before submitting. Your information will be reviewed by our clinical team prior to your appointment.