• Your name, address, telephone number, and other contact information.
• Your age, gender, and occupation.
• The name of your referring physician (or other person who referred you).
• The major medical problems that affect you and their duration.
• The symptoms you’re experiencing and the specific areas or organs of your body that are affected. Providing details of when and in what circumstances these symptoms occur is often vital to establishing an accurate diagnosis.
• For women, let your physician know if you think or know you are pregnant or if you are planning to become pregnant.
• Aggravating factors that seem to make your condition worse. For example, if you notice that your respiratory symptoms - such as coughing, wheezing, or shortness of breath - are more severe when you visit people who have pets or when you’re around smokers, make sure you tell your physician.
• The names of all the medications you’re currently taking, including products that you use specifically for your condition, as well as other drugs such as over-the-counter (OTC) preparations or herbal remedies that you take to relieve minor aches and pains. If you’re unsure of the actual drugs that you use, bring the medication with you in its original container. Also, ask your pharmacist, primary care physician, or other doctors for a list of medications they’ve prescribed for any of your medical conditions. Because gathering this information all at once can be a challenge, keep a medication record that you can refer to when consulting with a new doctor.
• If you’ve been treated or evaluated previously for the same condition, provide your new doctor with information on the results of these consultations and treatments. Bring the results from any tests you’ve had in the past.
• Providing accurate information on any other illnesses and related treatments you’ve had is also vital to evaluating your current condition.
• Your family history is very important in determining your diagnosis, so take time to list this information to the best of your ability. Likewise, if you fill out this form for a child, provide information on specific childhood factors, such as birth history, immunizations, and childhood illnesses.
• Your career, occupation, the school (or day care for children) you attend, and your hobbies or recreational activities are also important factors in figuring out what’s ailing you.
• Your dietary history, including any special diets you follow, major food groups you avoid, and whether you’ve been diagnosed with any food allergies.
• Your specialist needs to know about your home because many things in your domestic environment can trigger or aggravate allergy and/or asthma symptoms, particularly dust, animal dander, molds, and tobacco smoke. Therefore, you should provide your doctor with information on the following items:

1. A list of the people living with you and any habits they may have, such as smoking or keeping pets, that could affect your condition.
2. If you have plants in your home, make sure you can identify them for your doctor.
3. Information about your home such as its location, age, principal construction materials, air circulation system, condition of the basement, and type of carpets and furnishings you have. Your doctor may also ask about your yard, garden, and surrounding vegetation.
4. Your doctor usually asks about your bedroom also. Because the bedroom is where you most likely spend the majority of your life, exposure to allergens in your bedroom can often play a significant role in the severity of your allergy or asthma symptoms.

Reprinted from Allergies and Asthma for Dummies by William Berger, M.D. Available wherever you buy books.

Find a physician near you! Check out AANMA’s Physician Locator, the American College of Allergy, Asthma and Immunology’s Allergist Locator, or the American Academy of Allergy, Asthma and Immunology’s Physician Referral System.