Moderate None Mild Severe Remarks: LUNGS / BREATHING: Cough Wheezing Shortness of breath Chest Tightness Are these symptoms CONTINUOUS Continuous Episodes Or do they occur in EPISODES? Do the above symptoms limit your No Yes How often: activity Do these symptoms wake you at night? No Yes How often: Have you been diagnosed with asthma? No Yes Have you been diagnosed with COPD, No Yes emphysema, or chronic bronchitis? Are you currently using any inhalers or No Yes nebulizers to help you breathe easier? Have you used any inhalers in the past? No Yes Have you been given oral steroids for No Yes How often: breathing symptoms (ie Prednisone, Medrol) Last Have you required Emergency Room care for No Yes How breathing symptoms? Last ER visit: Have you been hospitalized for No Yes How often: breathing symptoms? Last Hospitalized: Have you had any pulmonary function No Yes Details: (breathing) testing? Have you ever had a Chest Xray? No Yes Last done: Findings: SKIN / RASHES Remarks: None Mild Moderate Severe (red, raised, itchy blotches) Swelling of the skin Eczema / Atopic dermatitis Contact dermatitis Itching WITHOUT any rash Other rash / not sure Does it itch? No Yes Does it burn or hurt? No Yes Are there bumps? No Yes Are blisters? No Yes How long has it been present ____ days _____ weeks _____ months Is this a CONTINUOUS rash or Continuous Episodes does it come and go in EPISODES? How long to individual lesions last? ____ hours _____ days _____weeks Where does the rash START? What body part(s) are affected? Do any of the following make the rash worse: Dry Skin? No Yes Heat (ie hot tubs, heaters)? No Yes Exercise? No Yes Cold? No Yes Foods? No Yes List: Any relation to No Yes Medications? No Yes Other triggers you suspect:
LUNGS / BREATHING: None Mild Moderate Severe Remarks: Cough Wheezing Shortness of breath Chest Tightness Are these symptoms CONTINUOUS Or do they occur in EPISODES? Continuous Episodes Do the above symptoms limit your activity No Yes How often: Do these symptoms wake you at night? No Yes How often: Have you been diagnosed with asthma? No Yes Have you been diagnosed with COPD, emphysema, or chronic bronchitis? No Yes Are you currently using any inhalers or nebulizers to help you breathe easier? No Yes Have you used any inhalers in the past? No Yes Have you been given oral steroids for breathing symptoms (ie Prednisone, Medrol) No Yes How often: Last Have you required Emergency Room care for breathing symptoms? No Yes How Last ER visit: Have you been hospitalized for breathing symptoms? No Yes How often: Last Hospitalized: Have you had any pulmonary function (breathing) testing? No Yes Details: Have you ever had a Chest Xray? No Yes Last done: Findings: SKIN / RASHES None Mild Moderate Severe Remarks: (red, raised, itchy blotches) Swelling of the skin Eczema / Atopic dermatitis Contact dermatitis Itching WITHOUT any rash Other rash / not sure Does it itch? No Yes Does it burn or hurt? No Yes Are there bumps? No Yes Are blisters? No Yes How long has it been present ____ days _____ weeks _____ months Is this a CONTINUOUS rash or does it come and go in EPISODES? Continuous Episodes How long to individual lesions last? ____ hours _____ days _____weeks Where does the rash START? What body part(s) are affected? Do any of the following make the rash worse: Dry Skin? No Yes Heat (ie hot tubs, heaters)? No Yes Exercise? No Yes Cold? No Yes Foods? No Yes List: Any relation to No Yes Medications? No Yes Other triggers you suspect:
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