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3160 Crow Canyon Road Suite 120, San Ramon, CA, 94583
TF (925) 275-1990 F (925) 275-1993
biovedaofsanramon.com
Although your history and symptoms are very important in our analysis of your condition, it is also
important for us that you understand:
Briefly describe the reason for your visit and what you hope to accomplish:
DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST
BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?
HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?
Yes and allergy shots helped Yes but allergy shots did not help
Yes and medication helped Yes but medication did not help
None
Mother Father
Brother/Sister Grandparents
Son/Daughter Spouse
None
__ When exposed to tobacco smoke __ With yard work, cut grass, leaves, hay or barns
__ Bees __ Other
__ None
Waterman Chiropractic and Allergy/Migraine Relief Center
3160 Crow Canyon Road Suite 120, San Ramon, CA, 94583
TF (925) 275-1990 F (925) 275-1993
biovedaofsanramon.com
FOOD RELATED SYMPTOMS
__ Symptoms flare 5-60 minutes after meals __ Some foods are craved or
addictive
__ The smell or odor of some foods increases symptoms __ Some foods cause nasal
symptoms
__ Some foods cause swelling of the mouth or tongue __ Some foods cause rashes or
hives
__ Some foods cause upset stomach or vomiting __ Some foods cause diarrhea
__ Symptoms occur with restaurant salad bars or Asian foods __ Some foods cause headaches
__ Symptoms occur with any regularly eaten food __ Some foods cause asthma
FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE
__ None
__ Newsprint __ Other:
__ None
Waterman Chiropractic and Allergy/Migraine Relief Center
3160 Crow Canyon Road Suite 120, San Ramon, CA, 94583
TF (925) 275-1990 F (925) 275-1993
biovedaofsanramon.com
WHEN ARE YOUR SYMPTOMS WORSE __ Year around
MEDICATIONS
__ Bronchodilators (Albuterol, Ventolin, Proventil, Serevent, or OTS’s such as Primatine Mist, etc)
__ Medications that affect the immune system (Prednisone, Imuran, Methotrexate, Cellcept, Cyclosporine,
Tacrolimus, etc)
__ Chemotherapy
SMOKING
Do you presently smoke? __ Yes __ No If yes, average number of cigarettes per day
If yes, at what age did you start?
Does anyone smoke in your home? __ Yes __ No
Waterman Chiropractic and Allergy/Migraine Relief Center
3160 Crow Canyon Road Suite 120, San Ramon, CA, 94583
TF (925) 275-1990 F (925) 275-1993
biovedaofsanramon.com
WORK ENVIRONMENT