ALLERGY REPORT

SAI NETRALAY AND SPECIALITY CLINIC

2. Araneshwar Park Phase lIl above ICICI bank, sahakar Nagar ph no 24221184 mobile no

7719800464
national Faculty by Indian
Vijay Warad Allergy Asthma Specialist, Master Trainer and
Dr.
Academy of paediatrics on Allergy & Asthma, Member World Allergy Organisation

Dr. Vrushali warad - MBBS, DOMS, DNB EYE Surgeon

NAME VIHAAN DHAGE Age: 2 DATE: 19/11/20211

Sr. Allergens Sr. Allergens

No.
mm

Saline
mm 24 Nettle (skin prick)
0 mm
HT5Tt
2|Histamine
mm
25Locust Black(floormite)
4 mm{
mm 20Acarus siro (stoor mite) HTOTAT H
Timothy Grass
4 m
mm Lepidglyphus DestrescentiaetS
|Lamb'sI11 quarterS
Smm 28 Tyrophagus putrescentiae miy
Bermuda Grass
mm
Te
Mugwot
mm
29 Rye Grass
mm 30 Grain dust rice
Short Ragweed
31 Polised dust mm
orn
mm
Kentuaky Blue grass
mim 52Alternaria allernala T 5UT
mmi
mm 33 Urvalaria iunata
O Partheniun mm

Dermatophagoides Fairance oTTT Fasarium solanii TI U

HTo3T mm
Dermato plerny ssinus YSTATT ThEU
0 mm Cyprus rotundus (pollen)
mn
mm 36|Putrajiva roxburghii
1iAspergilles Funigatus TaHiaRTA
mm
mm5Eucalyptusspp etTNT
Aiternaria tenuis
nucifera (pollen) N@
15|Cladosporium mm 8|Cocos
mm
mm PSamania saman R13IchU
6 Penicillium notatum

mm A c a c i a Arabica TH
7| Rhizopus higricans
mm
mm41|Casurrina equisetifola (polien)
18|Botryiis Cinerea
mm
mm 42|Cassia siamea (pollen)
JTTE
Cow epithelia mm
mm 45|Peltophorum pierocarpum JtoHTET
20 Wheat (pollon) --
44 Ricinus com:tnis
0 mm
2Cat epithelia 45Holoptelea interyrifolia (poilen)
mm
Fusarium Moniliforme
im

Heminthosporium Halodes atATU

Hm 46 Allanthous excels (pollen)

AXI'n
Human dancer mn
80|Chenopodium albim mim

*Dog epithelia cn>t aa mm 81 Xanthium stramarium- mm|

4Sheeps wool mm
82Honey bee-- HHTRtT n mm
--
Pigeon dropping 3ITYT mm 83 Ants black-- mm

Pigeon ferther hsNTT Ta 84 Cricket-- fsT mm

-Chichen ferther aitas ue mm

8|Ant red-- O mm

4 min
Blomia sp-Ecolcie cU] 0 mm
o0Grass hopper ThST
Silk dust- ettA mm| 87 Wasp mm

Cockroarth 0 mm 88 Rice weevil-- fhST 4 mm

6|Moth G3T mm
89|Souf mn

S7House fly HTRT mm 90 Chivdas mm

58 91 Saw Dust
Caria papa a us mm mm

Sorghum vulgare TANT ANm|

92Tricoderma sp KTTE mm

o0 Pennisetum typhoids mm 93 Candida albicans mm

Argcmone Mexicana toaTgtAT mm 94 Aspergillus tamarill mm

-Brassica nigra TOTCUT mm 95 Rhizopus nigricans mn

0 Prosopis Julitlora mm 96 Aspergillus flavus mm

64|Iponr:oea sp-- mm97|Ageratum conyzoides mm

0Cassia occidentalis 357 NST Tm| 98 Vinegar mn

00 Magnifera indica-- TsT mm 99 Yeast mm

6Azadirachta indica mIn100|Pineapple toioF m

68 Ty pha angustata mm 101Spinach 9T mm

69 Buffalo dander-- mm102 Shrimp HTHT mni

70Aspergillus versicolor-- mm 5 Salmon mm

71 Phpma tropicals-- mm 04 Chicken mm

72 Altermaria aitemata- mm05|Hens egg (white) HgATAT YTET MT mm

3Aspergillus niger- mm06 Hens engg (yellow) 3_AT ESTHTT m

Mosguito 3H 4 hm0/|Peanut
/Chenopodium maralan 5eTTYRTOTChUT m 108Wheat flower 3c6Tuo
Cenchras barbatus-- lTRTIT5UT mmTO9 Grape AT&T
77 mm 0|Orange HM mm
Dodanaca viscose el4RTT5UT
78 Pithoce llibium-- 5TTNTUT mn 11Banana
Amaranthus spinosus- 7T7RTØTFUT -

mim12Potato

Since when have you been smoking

.

Yugaretes do you have in a day

 mm
sCows Milk m 46|Onion
mm
14Pea TTETUT mm4/Tamarind
min
Corn lower mm148 Raddish HGbT
mm
1oCaulitlower mm 9|Cabbage
mmn
117Mutton HC 150Tendli
mm
118Dalda mm
151 Suran
19 Butter 4 mm
152Carrot JI|GR
mm
120 Curd mm
i5Pumkin 3HTYOT
mm
Tobacco T imm Drum stick
min
122|Latev mm 15Snake gourd
mm
123 Turai RIIsT5 mm56|Vaal
mm
i24 Gartc mm /Bitter gourd
mm|
Watermelon mm18Cinnamon
mim
126Pancer mm 9Celeray
mm60|Snoth mm
Mushroom #R
128|Cheese as mm 16!AImond mm

mm 162 Pear mm
I29|Lemcn Grass
mm
I30Guava t mm16s Saffron
131 Mango ¥ot TaT mm 64Rad pumkin mim

Straw berry FSRT mm

165Clove
mm
133Cherry aNT mm 166|Rajma IGTHT

134 Peach mm 167|Gum mm

mn
135 Anjeer mm 68| Ajinomoto
mm
136Rose Appie mm 6|Cardamum
mm
37 Apple uE mm170|Waternut
m
8Chikoo e mm| T/Sesameseed
mm172|Cunmin seed GR m
39Sugarcane
mn
140 Lemon 175|Coconut
141Tomato mm 17Chiili powder
min
142Sweet potato inn 175|Plum
145 Brinjal mm176|Ghevada tasT
mm 177|Sweet gourd mm
14+Cucumber 51chST
m
145 Ginger 3HG mm178P'apadi Tqst

asi SIIURer
If yes, How many cigarettes do you have in a day? Since when have you been smoking
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 SAI NETRALAYA AND SPECIALITY CLINIC
(Allergy, Asthama & Eye Hospital)
Araneshwar Park, Phase i, A2 Wing. First Floor/102,Araneshwar, Pune.
ALLERGY QUESTIONNAIRE

Name of the Physician and Clinic:

heh 2A Date: / " 2
PATIENT DETAILS 7711
Name VVa n h Sex: Male Female
Age:years
Occupation:. Mobile Number 72 76 SiS72
CURRENTHISTORY
Do you have any of the following symptoms (please tick all that are applicable):
RESPIRATORY TRACT EYES DRY SKIN GASTROINTESTINAL OTHERS
O Asthama
nasal itching Itching itching Oabdominal pain
runny nose watery redness Onausea orvomitin8 Snoring
Oblocked nose redness swelling diarrhoea Drug Rash
Mouth Ulcer
sneezing swelling s k i n rash or eczema Obelching or gas formation |
dak circlees indigestion Itching, rubbing ears,
Ochronic cough Pimples
shortness of breath Discharge Boils Acidity nose, throat.
Blinking Constipation Tickling or clearing throat
chest tightness Wrinkle Fungal Infections
When do you suffer from allergic symptoms: Seasonal (during some specific months) Perennial (all year long)
Perennial with seasonal exacerbations (all year long with some seasonal increase in symptoms)

During which months do you get symptoms repeatedly (Please tick the months when you get the sympoms repeatedly):
Feb May Jun Jul Aug Sep O Oct Nov Dec
Jan Mar Apr
How long do your symptoms last? S
More than 4 days per week: O Yes No More than 4 weeks at a stretch: Yes O No

No Alittle Moderately Prevents normal activities

Do your symptoms affect your day-day activities?
D o your symptoms disturb your sleep? Yes No

PRECIPITATING FACToRS/TRIGGERS
(select locations all that applicable)
Are your symptoms worse in the following
Indoors Outdoors At home At work At school Others(please mention)
Are your symptoms worse at the following time (select all that are applicable):
Morning Afternoon Evening Night All day long
Are your symptoms worsened by any of the followingtriggers(select all that are applicable):

Walking in a garden D u s t or dusty atmosphere Physical exertion or exercise

Sleeping or lying on a bed OSmog or pollution exposure Soaps, detergents, or cosmetics
Damp areas After eating particujar food items AnyPlease
other
mention
Exposure to animals / pets Please mention y u k iu
Please mention

PAST HISTORY
Have you been hospitalized or had a severe (anaphylactic) reaction because of your allergy/allergies? Yes No

Have you ever been skin tested or had a blood test or allergies? Yes No Test date:
To which allergies did you test positive:
before? Yes No
Have you received allergen immunotherapy or allergy vaccine
If yes, for which allergen/s did you receive innmunotherapy?
For how many years did you receive it
When was it initiated :
Good O Mild None
What was your response to therapy: Significant
MEDICATION HISTORY
FAMILY HISTORY What medications have you used to treat
Has any member of your family had any
you allergy and/or asthma symptoms?
ofthe following allergies (Please tick Type Route FrequencyY
Parents Siblings Children Oral Nasal
Asthama H1 antihistamine 0Opthalmic
Allergic Rhintis Oral Nasal
Corticosteroid
Skin Allergy Inhaled Topical
Food Allergy Bagonists
Number of siblings:. other (pleasespecify
Number of children:

SMOKING HISTORY
Y e s N o Past smoker
Are youHow a smoker?cigarettes Since when have you been smoking,
If yes, many do you have in a day?.