NEW PATIENT FORMS FOR ADULT. Patient Last Name First Name Middle Name. DOB Age Race SSN. Sex Single Married Widowed Divorced

Transcription

1 The Allergy and Asthma Center f Crpus Christi 1718 Braeswd Dr, Crpus Christi TX text: Fax: NEW PATIENT FORMS FOR ADULT Patient Last Name First Name Middle Name DOB Age Race SSN Sex Single Married Widwed Divrced Cell phne Hme phne Wrk phne Address City, State, Zip Occupatin Emplyer Name Address City, State, Zip Spuse Name Scial Security # DOB Cell phne Hme phne Wrk phne Address ( if different ) City, State, Zip Occupatin Emplyer Name Address Primary Insurance Name f Plicy Hlder Secndary Insurance Name f Plicy Hlder **Hw did yu hear abut us? Patient Signature Date _

2 HIPAA COMMUNICATION AUTHORIZATIONS I/We authrize Allergy and Asthma Center t leave messages r discuss my PHI with the names listed belw: Cntact Persn Relatinship Primary Care Dctr Referring Dctr Other Dctr Other Dctr I authrize Allergy and Asthma Center f Crpus Christi t use the fllwing frm(s) f cmmunicatin when cntacting me abut upcming appintments, my medical care, my prescriptins, and/r my bill with the practice. (Please set 1, 2. as yur pririty) Text cell phne Call Vic Cntact persn Cell phne Hme phne Wrk phne Patient Signature Date Pharmacy Name Preferred Retail Pharmacy Phne Number Address Stre Number

3 Patient First Name Last Name Date f Birth Please check any f the fllwing Symptms that yu are currently experiencing r that yu have had recently Nasal Symptms Past Present Nasal cngestin Runny nse Nasal discharge Pstnasal drip Snring Nasal itching Frequent sneezing Frequent nse bleeds Nasal plyps Lss f sense f smell Lss f sense f taste Sinus Past Present Frequent infectins Pressure in sinuses Pstnasal drip Nighttime cugh Sinus headaches Bad breath Hw many times in the last year have yu taken an antibitic fr a sinus infectin? Is s, when was the last time? Have yu ever had a sinus CT (CAT scan) r x-rays? N Yes If yes, when was mst recent ne? Have yu ever had sinus surgery? N Yes. If yes, date: Eye Symptms Past Present Frequent Ear Infectins Past Present Have yu had pressure equalizatin tubes? N Yes If yes, date(s): Ear Symptms Past Present Pain Itching Pressure Lss f hearing Headaches Past Present Sinus Migraine Tensin With menses Lcatin f headaches Frntal Back f head Temple area One-sided Is yur headache Sharp pain Dull pain Thrbbing pain When yu have headaches, d yu have nausea r vmiting? d yu have difficulty with visin? are yu bthered by light? are yu bthered by nise? Frequency f headaches Daily Weekly Occasinally Seldm Lung Symptms Past Present Asthma Wheezing Chest clds r cngestin Chest symptms with exercise Shrtness f breath at rest Shrtness f breath at night Sudden attacks f shrtness f breath Pneumnia Brnchitis Brnchilitis Crup Cugh Cughing up bld Gastrintestinal Past Present Frequent nausea r vmiting Frequent episdes f diarrhea Heartburn Regurgitatin f fd Acid r sur taste in yur muth in the mrning Abdminal cramping Itching f muth r thrat Fd allergy: list which fds Itching Watery eyes Effective medicines fr headaches (list names): Skin Symptms Past Present Hives Itching Redness r burning Swelling f eyelids Eczema Cntact ras WHICH OF THE FOLLOWING TRIGGER FACTORS MAKE YOUR SYMPTOMS WORSE? (check all that apply) Brnchitis Nighttime Fd additives (specify) Clds, influenza Sinus infectins Nnsteridal antiinflammatry medicines (such as ibuprfen r Weather changes Cutting grass Cats Dgs naprxen) Other animals (specify) Laughter Aspirin Strng emtins r stress Exercise Fds (specify) Menstrual cycles Wines, alchlic beverages Damp, musty places Cigarette smke Huse dusting r vacuuming Perfumes, hairsprays, strng drs Occupatinal expsures Cld air Air pllutin

4 ALLERGY HISTORY Are yur symptms: Year-rund Seasnal Other If seasnal, which seasn(s)? (check all that apply) Spring Summer Fall Winter Which mnths are wrse fr yu? January February March April May June July August September Octber Nvember December Have yu had allergy skin testing? Yes N If yes, test date by Test results: Have yu had allergy shts? Yes N If yes, started date ended date Did allergy shts help yur symptms? Yes N Please list all knwn inhalant, fd, and medicine allergies ther than thse detected nly by skin testing: WHAT YOU ARE ALLERGIC TO REACTION D yu have any ther allergy prblems, such as latex sensitivity r insect sting allergy (bee, wasp, yellw jacket, hrnet, r fire ant)? Yes N If yes, please list: USE OF MEDICATIONS Please list all current ORAL and INHALED medicatins prescribed by yur dctr and any nnprescriptin medicines yu are taking: MEDICATION & STRENGTH HOW MUCH & HOW OFTEN MEDICATION & STRENGTH HOW MUCH & HOW OFTEN Please list medicatins yu have taken in the past but n lnger are taking fr the symptms being evaluated here:

5 List all hspitalizatins r Nne MEDICAL HISTORY DATES OF HOSPITALIZATION NAME OF HOSPITAL REASON FOR HOSPITALIZATION Please list all surgical prcedures and the date they were dne r Nne PROCEDURE DATE ASTHMA SEVERITY Have yu been admitted t hspital because f asthma? N Yes. If yes, hw many in the last year? Have yu been admitted t an Intensive Care Unit because f asthma? N Yes. If yes, when? Have yur asthma symptms resulted in respiratry arrest, intubatin r use f a mechanical ventilatr? N Yes List any previus testing yu have had r Nne APPROXIMATE DATE Chest x-ray Sinus CT r x-ray Sweat chlride test Pulmnary functin tests Barium swallw Naspharyngscpy r laryngscpy Esphagscpy Brnchscpy Immunglbulin studies Other Have yu had any f the fllwing r Nne? Cataracts Diabetes Thyrid disease Elevated chlesterl RESULT Hiatal hernia Irritable bwel syndrme Any severe infectins Other medical prblems? Migraine headaches Heart disease High bld pressure Pneumnia Cancer Hepatitis Gastresphageal reflux Psitive tuberculin skin test Osteprsis SOCIAL HISTORY (check all that apply) Alchl use: drinks per week N Alchl use At risk fr HIV infectin (unprtected sex, IV drug use, histry f bld transfusins) Histry f drug use Smking Status: Current If current: packs per day Frmer (when quit: _) Never smked Secnd hand smke expsure: Envirnmental Occupatinal Perinatal/befre birth Tbacc use (ther/chew): _

6 REVIEW OF THE SYSTEM Please Circle 'Yes' Or 'N' Fr All Items Belw (Prblems yu have had within the past 3 mnths) ALLERGY/IMMUNE GASTROINTESTINAL NEUROLOGIC Yes N Hayfever Yes N Abdminal pain Yes N Frequent headaches Yes N Swllen glands r ndes Yes N Bld in stl Yes N Head injury Yes N Weak immune system Yes N Cnstipatin Yes N Lss f cnsciusness Yes N Diarrhea Yes N Numbness arund muth CARDIOVASCULAR Yes N Difficulty swallwing Yes N Numbness r tingling Yes N Chest pain Yes N Heartburn Yes N Seizures Yes N High bld pressure Yes N Nausea r vmiting Yes N Tremrs Yes N Palpitatin r heart racing Yes N Swelling in legs r feet GENITOURINARY NOSE and SINUSES Yes N Bld in urine Yes N Frequent clds EARS Yes N Frequent urinatin Yes N Nasal stuffiness Yes N Ear aches Yes N Kidney stnes Yes N Sinus trubles Yes N Ear infectins Yes N Lss f bladder cntrl Yes N Hearing prblems PSYCHIATRIC Yes N Tinnitus HEMATOLOGIC/LYMPH Yes N Anxiety Yes N Vertig Yes N Anemia Yes N Depressin Yes N Bld transfusins ENDOCRINE Yes N Easy bruising r bleeding RESPIRATORY Yes N Breast discharge Yes N Asthma Yes N Diabetes INTEGUMENTARY (Skin) Yes N Frequent cugh Yes N Excessive thirst Yes N Changes in hair r nails Yes N Shrtness f breath Yes N Heat r cld intlerance Yes N Dryness Yes N Spitting up bld Yes N Thyrid prblems Yes N New stretch marks Yes N Wheezing Yes N Rashes EYES Yes N Blurry visin MOUTH and THROAT Yes N Duble visin Yes N Dry muth Yes N Glasses r cntacts Yes N Frequent sre thrats Yes N Glaucma Yes N Sre tngue GENERAL Yes N Fatigue Yes N Fever Yes N Lss f appetite Yes N Night sweats Yes N Recent weight change MUSCULOSKELETAL Yes N Back pain Yes N Muscle cramps Yes N Muscle weakness Yes N Neck pain Yes N Swelling r pain in jints Patient (r Patient ) Signature Tday's Date: