Offices

St. Charles
2900 Foxfield Rd.
Suite #206
St. Charles, IL 60174
Tel: 630-584-6127
Fax: 630-584-6070

Answering Service
630-208-4234

DuKane Allergy Asthma Associates, Ltd. - Initial Evaluation
 
 
To streamline your first office visit, you may complete your portion of the medical history prior to your appointment. This will enable our physicians to learn about your needs prior to your initial evaluation, so that we may provide you the most optimal and efficient treatment.
(* Required)

First name:  * Last name:  *
Date of birth:
(MM-DD-YYYY)		  * Sex:  *

What is the reason for your visit? *
Please be specific. (i.e. worsening asthma, frequent infections over past 12 months, suspected peanut allergy, etc.)
This will enable us to help you more than stating "need allergy testing", for example.
Who referred you to our office? *
We communicate with referring physicians to maintain continuity of care.
Who is your primary care physician? *
We communicate with primary care physicians to maintain continuity of care.
Have you ever been evaluated by an allergist/immunologist? Yes
No
Have you ever been treated with immunotherapy ("allergy shots")? Yes
No
If you have received immunotherapy in the past, when?
Please include date started and duration of therapy.
Date started:        Duration of therapy:  
Past Medical History
Please list medical conditions you have experienced in the past or are currently experiencing. Please include date of onset.
  Date of onset Medical condition
1)
2)
3)
4)
5)
What is your occupation? *
Please include how long you have been in this profession.
Past Surgical History
Please list past surgical procedures with their corresponding dates.
  Date of surgery Surgical procedure
1)
2)
3)
4)
5)
Hospitalization History
Please list past hospitalizations (Date, Hospital, Reason)
  Date of hospitalization Hospital Reason
1)
2)
3)
4)
5)
Drug Allergies
Please list name of medications and reactions experienced.
  Name of medication Reaction
1)
2)
3)
4)
5)
Current Medications *
Please list current medications (Name of drug, dose, frequency, when started). Include "as needed" medications, over-the-counter medications, and nutritional/herbal supplements.
  Drug name Dose Frequency Date started
1)
2)
3)
4)
5)
Food Allergies
Please list foods and reactions experienced.
  Food Reaction
1)
2)
3)
4)
5)
Stinging Insect Reaction
Have you experienced a reaction to an insect sting? Please check all that apply.
 
 
 
Other: 
Where do you live?
  
What type of heating do you have?
  
Do you have carpeting in your bedroom? Yes
No
Do you have air-conditioning? Yes
No
Pets
Please list any animals which reside in your home or with which you have regular contact.
What is your exposure to tobacco smoke?
Please check all that apply.
 
If you are an ex- or current smoker, approximately how many packs of cigarettes per week did/do you smoke?
Do any of your blood relatives (grandparents, parents, siblings, children, grandchildren) have the following conditions?
Please check all that apply.
Other: 
Are your childhood vaccinations up-to-date?
Yes
No
Do you receive a yearly influenza vaccine?
Yes  -  Date of last dose:
No
Have you received the "pneumonia vaccine" (Prevnar or Pneumovax)
Yes  -  Date of last dose:
No
Review of Systems - Are you experiencing:
Please check all that apply.
General
 
 
Cardiovascular
 
 
Eyes
 
Respiratory
Skin
 
Head and Neck
Musculoskeletal
Hematological
Gastrointestinal
Endocrine
Neuro/psychological