Questionnaire

Auckland Allergy Clinic Questionnaire

AllergyDoctor & COAST Questionnaire

To address the growing gap between the rising prevalence of allergies and the shortage of Allergy Specialists in New Zealand, the idea of AllergyDoctor was considered the most realistic solution to improving the unmet needs of Allergy Service in New Zealand. The core structure of AllergyDoctor is to train/up skill General Practitioners in Allergy. They are trained to be proficient in comprehensive Allergy Assessment, skin prick testing, patch testing and administering immunotherapy, safely and effectively. Each clinic also has a nurse trained in administering intradermal, subcutaneous injections and skin prick testing. The nurse is also trained (and encouraged to attend regular meetings) in patch testing.

In AllergyDoctor, the task of the General Practitioner in Allergy Assessment is made easier through the use of The Comprehensive Online Allergy Screening Tool (COAST™). This helps the GPs in AllergyDoctor to be able to diagnose more difficult allergies using the probability logic technique of COAST™, a virtual allergist, using clickable algorithms to arrive at a probable diagnosis. After an appointment is made with AllergyDoctor GP and an individualized Allergy Management Plan (including all appropriate investigations and treatment) is created based on International Evidence Based Allergy Practice using the guidelines of the Australasian Society of Clinical Immunology (ASCIA), the British Society of Clinical Immunology & Allergy (BSACI), the European Academy of Allergy and Clinical Immunology (EAACI), and the American Academy of Allergy, Asthma, and Immunology (AAAAI), the professional bodies to which the Consultants in AllergyDoctor are members of COAST is also very useful tool for excluding allergies.

At the present time patients in both the public and private health system can have specific IgE (formerly RAST) test requested by any doctor free of charge, but like all the other cut-backs in the health system it is rumored that this service will not be free for much longer. Hence plans as outlined below to introduce Specific IgE & Component (molecular) allergy testing in AllergyDoctor NZ clinics.

Before your first visit to Auckland Allergy Clinic we will ask you to fill in the Questionnaire below. Filling in this form and submitting it will allow us to be familiar with your history before your visit.

Date
Patient Name
Parent/Guardian Name
Occupation
Ethnicity
Address
 
Date of Birth
Phone (Work)
Phone (Home)
Email
N.H.I No: (if known)
Do you have Medical Insurance?   Yes No
Company
GENERAL PRACTITIONER'S DETAILS
Name
Address
 
List your main symptoms or complaints (with duration):
A:
B:
C:
D:
List ALL medicines you take (including herbal, vitamins, etc.):
 
None
Answer ALL the following questions by ticking either YES or NO.
Any comments regarding these questions can be entered below.
Have you had Allergy Tests before? Yes   No
Have you had Immunotherapy (desensitisation) before? Yes   No
Have you ever had a severe reaction to a Bee or Wasp sting? Yes   No
How did this reaction manifest itself?
 
Have you ever had an Anaphylactic Reaction?
(Sudden severe collapse/shock after food, drugs or any cause.)		 Yes   No
What was the cause?
 
Is your condition seasonal? Yes   No
If so, which season is worse?
 
How often do you have your attacks?
 
How long do they last?
 
Do you suffer from Asthma? Yes   No
Do you suffer from Eczema? Yes   No
Do you suffer from Hives (Urticaria)? Yes   No
Do you suffer from Hay Fever? Yes   No
Do you suffer from Sinus Troubles? Yes   No
Do you suffer from Frequent Colds? Yes   No
Do you suffer from Persistent Cough? Yes   No
Do you suffer from Diarrhoea? Yes   No
Do you suffer from Abdominal Cramps? Yes   No
Comments
CONTACT ALLERGY
Have you ever had a skin reaction to Jewellery? Yes   No
Have you ever had a skin reaction to Skin Care Products / Cosmetics? Yes   No
Have you ever had a Patch Test? Yes   No
CHILDHOOD ALLERGIC HISTORY
Did you have Asthma? Yes   No
Did you have Eczema? Yes   No
Did you have runny nose (Rhinitis) / Hay Fever? Yes   No
Did you have Vomiting, Diarrhoea or Colic? Yes   No
FAMILY HISTORY
Have any of your first degree relatives (parents or siblings) had:
Asthma? Yes   No
Relationship
Eczema? Yes   No
Relationship
Rhinitis (Hay Fever)? Yes   No
Relationship
FOOD HISTORY
Do you suspect any foods as causing symptoms? Yes   No
Which one(s)
Are you omitting any food(s) at present? Yes   No
Which one(s)
ENVIRONMENTAL HISTORY
Do you have a Cat? Yes   No
Do you have a Dog? Yes   No
Are your symptoms better on Holidays? Yes   No
Are you worse at Work? Yes   No
Do you have any Hobbies? Yes   No
DRUG HISTORY
Are you sensitive / allergic to any Drugs? Yes   No
Which one(s)
EXERCISE HISTORY
Are your symptoms brought on or worsened by Exercise? Yes   No
GENERAL MEDICAL HISTORY
Have you ever had an operation on your Sinuses? Yes   No
Do you have High Blood Pressure? Yes   No
Are you a Diabetic? Yes   No
Are you Pregnant? Yes   No
Do you Smoke? Yes   No
NEWSLETTERS & UPDATES
Would you like to receive newsletters and updates from us? Yes   No