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Patient Information
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Patient's Name:
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Address1:
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Address2:
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City:
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State:
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Zip:
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Home Phone:
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Work Phone:
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Gender:
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Date of Birth:
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Age:
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Allergy Symptoms
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Do you have any of the following symptoms? |
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Ear, Nose, and Throat |
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Sneezing and/or nasal itchiness?
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Water nasal drainage?
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Nasal congestion, blockage, and stuffiness?
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Post nasal drip?
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Thick, cloudy, mucus discharge?
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Frequent "sinus" problems and/or infections?
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Frequent colds?
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Loss of smell?
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Recurrent sore throats?
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Itching of mouth, throat and/or palate?
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Swelling of tongue, lips and/or palate?
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Recurrent hoarseness and/or laryngitis?
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Recurrent ear infections?
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Popping or fullness in the ears?
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Hearing loss?
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Itching ears?
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Eyes
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Eye itchiness, watering, redness?
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Swelling or puffiness around the eyes?
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Chest
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Chronic dry cough?
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Chest tightness, congestion, and/or shortness of breath?
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Asthma (wheezing)?
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Asthma present only with exercise?
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Frequent pneumonia and/or bronchitis?
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Skin/Joints
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Eczema?
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Hives/urticaria?
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Allergic skin reactions (swelling)?
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Itchiness?
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Muscle or joint pain and/or vomiting?
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Gastro-Intestinal
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Indigestion, belching, gas, heartburn?
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Bloating?
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Diarrhea?
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Constipation?
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Nausea and/or vomiting?
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General
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Dizziness, unsteadiness, or light-headedness?
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Chronic headaches/migraines?
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Depression, anxiety or tension?
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Chronic fatigue or tiredness?
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Difficulty concentrating?
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Hyperactivity?
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