Allergy History Questionnaire Have you had allergy testing done in the past? Yes No If so, when and where was the testing done? Do you have animals/pets? Yes No What types of animals? Are they inside your home? In your bedroom? On your bed? Do you have any feather pillows? Yes No Do you have dust mite encasements on pillows or mattresses? Yes No Do you have a HEPA filter? Yes No Do you have a humidifier? Yes No Do you have a dehumidifier? Yes No Do you have central air conditioning? Yes No Do you open the windows of your home? Yes No Do you have an attic fan? Yes No What type of heat do you have? Gas Electric Ground source Wood burning stove Other Do you have a fireplace? Gas Wood burning If so, how often do you use it? Where do you live? Do you own or rent? House Manufactured home Apartment Do you own or rent? Own Rent How old is the place where you live? How long have you lived at this location? Do you have a basement? Yes No Is it finished or unfinished? Dry or damp? Do you have a crawlspace? Yes No Is there any history of water damage in your home? Yes No Do you smoke or have a history of smoking? I'm a current smoker I used to smoke I've never smoked before How much do you smoke per day OR when did you quit? Do you live with any smokers? Yes No If so, do they smoke inside? Yes No Do you chew tobacco? Yes No Do you drink? Yes No If yes, choose what you drink: Wine Beer Whiskey Do you have a history of alcohol or substance abuse? Yes No Are you on a blood thinner? Yes No Social HistoryMarital status Married Single Divorced Widowed Child Who do you live with? Where do you work? What is your occupation? Do you work outside the home? Yes No Do you feel worse at work? Yes No Are you exposed to any perfumes, chemicals, or irritants? Yes No If so, explain where and how much exposure you have: Δ
