Dr. SHAVINDER GILL, Inc. MB.BS, ABIM, FRCP(C)
DIPLOMATE OF AMERICAN BOARD OF INTERNAL MEDICINE
ALLERGIC AND CARDIAC DISEASES

CONFIDENTIAL
2415 Ware Street.
Abbotsford, BC
V2S 3C6	

URTICARIA PATIENT REGISTRATION FORM (Please write in Capital letters)

Full Name (Last, First): _____________________________________________
Home Address: ____________________________________________________
City: ABBOTSFORD/				Home phone: ______________			
Occupation: (Present or Past) ___________________________________
Marital status: Married/Divorced/Widowed/Separated/Single. 
Do you get hives? : YES/NO
How long ago the hives started? : 
Where did the hives started on the body for the first time? :
Did you have itching first before the hives started? : YES/NO
Did the rash started gradually or abruptly: YES/NO
How often do you get hives/rash: Daily or intermittently
When the hives started for the first time did you any of the following?
1. Did you have sinus or throat infection when the hives started for the first time? : YES/NO 
2. Did you have flu like symptoms when the hives started for the first time? : YES/NO
3. Did you have diarrhea or abdominal pain when the hives started for the first time? : YES/NO
4. Did you any other infection when the hives started for the first time? : YES/NO
5. Did you start any new prescribed medication, over the counter medication or herbal medication? : YES/NO 
6. Did you start any new soap, detergent, cosmetic? : YES/NO
7. Was there any physical or mental stress in your life? : YES/NO
8. Was there any change in home or work environment? : YES/NO
Did you ever have hives in the past? : YES/NO, If yes when?
Do you get them on whole body? : YES/NO
How long they stay? : 
Do the hives leave any scar? : YES/NO
Do the hives start after exposure to cold or warm environments? : YES/NO
Do the hives start after physical pressure on the body? : YES/NO
Can you think of any other things that bring on hives? : YES/NO. If yes then please specify_____________
MORE QUESTIONS ON THE BACK OF THIS PAGE
Do you have any liver disease? : YES/NO
Did you travel outside of Canada or go for camping? : YES/NO
Do you get any joint swelling or pain? : YES/NO
Do you get lip or eye swelling? : YES/NO
Do you get tongue or throat swelling? : YES/NO
Do you get cough, shortness of breath or wheezing? : YES/NO
Do you get itchy eyes/nose? : YES/NO
Do you get running eyes/nose? : YES/NO
Do you get sneezing? : YES/NO
Do you get nasal blockage or post-nasal discharge? : YES/NO
Did you ever have a severe reaction to Bee, Wasp or any other insect sting? : YES/NO
Are you allergic to any medication? : YES/NO
If yes then list them with type of reaction
	DRUG					REACTION WHEN TAKE
	_________________________		______________________
	_________________________		______________________
Please list all the medication with doses in space below (Capital letters please):
1.					2.					3.		
Do you have any food allergies? : YES/NO. If yes please list below with type of reaction.
FOOD					REACTION WHEN EAT
	_________________________		______________________
	_________________________		______________________
Smoking History: Do you smoke? : YES/NO
If yes,	Cigarettes per day_____		How Long________	Still smoking YES/NO
							If no when did you quit _____
Do you drink alcohol? : YES/NO. If yes how much and how often_________________
PLEASE LIST ANY OTHER HEALTH PROBLEMS. ________________________________
Signature: ____________________			Date: ____________________

I, the undersigned, being a patient of Dr. Shavinder Gill acknowledges that I have been informed the risk involved in the Allergy testing/_____________________. This may involves hives, swelling, asthma and or anaphylaxis.
Signature: ____________________			Date: ____________________

Read over and explained to the signatory and stated that the patient understood it an offered the signature in my presence. 
						____________________________________
						(Witness)