Frisco Allergy and Asthma Center (FAAC) Eric J. Schmitt, MD
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- Erik Miller
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1 November 30, 2007 Dear New Patient and Family: Thank you for selecting Frisco Allergy and Asthma Center for your allergy, asthma and immunology needs. Dr. Schmitt is board certified both by the American Academy of Pediatrics and by the American Board of Allergy and Immunology to treat both pediatric and adult patients. He has been practicing and serving residents of North Texas for over two years before establishing his own practice in The following is to serve as a brief introduction and provide an expectation for your initial office evaluation. If you have been diagnosed with asthma or have symptoms suspicious for asthma, you may complete pulmonary function testing (PFT). This test involves coordinated breathing maneuvers and can be performed in children occasionally as young as four years of age. Your test performance will be interpreted by the physician and is an integral part of assessment of asthma risks and impairment. For children too young to perform the test, Dr. Schmitt will use his experience and clinical judgment to diagnose and treat. Many patients will see an allergist for allergy testing. Skin testing may be performed and generally provides the most useful and reliable information about your allergies. Infants as young as six months of age may have limited skin testing. Skin testing involves scratching the skin in the presence of suspected allergens to observe for a local reaction (typically redness, swelling and itching, if positive). Testing can only be performed however in patients who are not currently taking antihistamine medications. Clearly, many allergy sufferers rely on their antihistamine medications for relief. Try not to be discouraged, since Dr. Schmitt may be able to treat your conditions using other medications or recommend other testing possibilities at your first visit. See the enclosed list of antihistamines to avoid, and feel free to call the office during business hours if you questions about specific medications not listed. Please expect your first comprehensive evaluation to take 1-2 hours. Your asthma and allergy testing may take roughly minutes each to complete. Please take the opportunity to complete (and even submit), your New Patient Medical History form ahead of time to expedite your visit. If you know what allergy testing you suspect you should have, you may be considered for testing before your physician evaluation. Many patients desire testing for a specific food allergen only, while others often know they will need a complete environmental allergen assessment. Rest assured, you may request your consultation first with Dr. Schmitt to permit him to decide what testing is most indicated. On behalf of the entire staff, welcome to the clinic! Our aim is to provide the highest quality of professional services, clinical judgment and patient education to each and all of you. We look forward to helping you obtain symptom relief and achieve control of your allergic conditions. Sincerest regards,
2 New Patient Registration Patient Name: M F DOB: / / SS#: (print) Address: City: Zip Code: Home Phone: Work: Cell: Name of Emergency Contact: Contact #: Married Single Divorced Relation: Relation to Insured: Self Spouse Parent Other: Primary Insurance Information Name of Primary Policy Holder: DOB: / / SS#: Employer: Address: Phone (H): Wk: Cell: Insurance Co.: Group #: Policy ID #: Benefit Verification Phone #: Secondary Insurance Information Name of Primary Policy Holder: DOB: / / SS#: Employer: Address: Phone (H): Wk: Cell: Insurance Co.: Group #: Policy ID #: Benefit Verification Phone #: Financial Responsibility FAAC will process insurance claims for my convenience. I understand that co-pays, deductibles and procedures not covered by my insurance are my responsibility. I understand that FAAC will attempt to verify my coverage, but if my insurance fails to reimburse despite these efforts, I am responsible for paying the bills in full. I understand that I am responsible for knowing what my insurance benefits are and obtaining referrals when required. I will inform any changes in my insurance plan immediately. Any charges that result from failure to do so will be solely my responsibility. Payments authorized for services performed are property of Eric Schmitt, MD PLLC. initial Patient/Parent Signature: _ Date: _
3 Medical History Patient Name: Date: Gender: Male Female Age: DOB: Primary Physician: Phone #: Preferred Pharmacy: Phone #: How did you hear about us? Doctor referral Ins. Co. Internet Other Patient Other ================================================================================ Reason for Office Visit: Describe briefly your most bothersome symptoms (duration, severity, previous therapies): Previous allergy testing: No Yes, if so, Physician name and location: Previous allergy shots: No Yes, if so, which years: Year: Asthma: Yes No Not Certain Previous lung function testing: No Yes, if so, when: Please list other current and former Medical Problems: Past Surgery History Sinus Surgery: No Yes, if so, when: Tonsillectomy: No Yes, if so, when: Other: Ear tubes: No Yes, if so, when: Adenoidectomy: No Yes, if so, when: Family History of: Nasal Allergies: No Yes, if so, relation to patient: Asthma: No Yes, if so, relation to patient: Eczema: No Yes, if so, relation to patient: Food Allergies: No Yes, if so, relation to patient: Recurrent infections: No Yes, if so, relation to patient: Other (please list): Social History (adult patients): Occupation: Tobacco use: No Yes, pack/years Quit, when: Pets: No Yes, list: Mold or known water damage in home: No Yes Women only, Pregnant No Yes Planning Other: Social History (pediatric patients): Day Care: No Yes, how many children: Tobacco exposure: No Yes, if so, by whom: Antibiotic use under age 1: No Yes, # times: Pets: No Yes, list: Mold or known water damage in home: No Yes Breastfed: No Yes, how long: Other:
4 Review of Systems: (please mark any or all that apply) General: growth concerns weight loss weight gain fevers night sweats Other Head: headaches dizziness seizures fainting spells sinus pain Other Eyes: redness itching/irritation dry eyes eyelid swelling conjunctivitis Other Ears/Nose/Throat: decreased hearing sneezing nasal drainage nasal congestion itching sinusitis nosebleeds sore throat snoring mouth sores Other Neck: swollen glands thyroid problems masses Other Heart: chest pain high blood pressure irregular heartbeats Raynaud s Other Lungs: shortness of breath chest tightness chronic cough recurrent pneumonia Other GI: heartburn/gerd lactose intolerance diarrhea vomiting abdominal pain Other Endocrine: diabetes heat/cold intolerance heavy/irregular menstrual periods Other Skeletal: joint pain muscle aches weakness Other Skin: hives eczema itching rash Other Psychiatric: depression anxiety mood swings Other Medications Please list all currently prescribed or over-the-counter Medications/Supplements: Name Amount and Times per day Every day As Needed Any medication allergic reactions: No Yes, if so please describe: Please list any medication side effect concerns, if any: I have read the additional notice regarding antihistamines and allergy testing. I have have not been able to withhold the listed and other antihistamine medications for the past seven days.
5 Medications and Allergy Skin Testing Allergy skin testing may be performed in the clinic to help diagnose your allergies. The test relies on detecting the effects of histamine that is released by the allergy cells of the patient. Antihistamines are widely used to treat a variety of medical problems, including allergies, by specifically blocking the effects of histamine release. Thus, antihistamines must not be taken to avoid interfering with the results of allergy skin testing. The effect of antihistamine medications last for a long time following discontinuation of these medications. It is recommended to stop all antihistamine medications for seven days prior to your scheduled skin testing. The following is a sample list of commonly used and prescription antihistamines that should be avoided: Over-the-counter Antihistamines Benadryl, Triaminic, Dimetapp, Tavist, Claritin, and other medications listing diphenhydramime or loratadine as an ingredient. Zantac, Pepcid and Tagamet used to treat heartburn or GERD. Most cold and allergy preparations contain antihistamines. Many sleep medications available and medications to prevent nausea and motion sickness contain antihistamines as well. Prescription Antihistamines Oral allergy medications including Allegra, Zyrtec, Clarinex, Periactin and Atarax (hydroxyzine). Astelin (azelastine) is an intranasal spray that contains antihistamines. Tricyclic antidepressants such as amitriptyline, imipramine, doxepin and others. ***IMPORTANT*** Please remain on all of your other medications that will not interfere with allergy testing. A partial list of these commonly used medications includes: Singulair and all of your inhaled or nebulized asthma medications Oral and intranasal decongestants including pseudoephedrine and phenylephrine. Guaifenesin Medications to treat GERD that are proton-pump inhibitors including Nexium, Prevacid, Aciphex and Prilosec. Antibiotics Steroids, including Solumedrol and Prednisone If there are any questions regarding any other particular medications, please contact the office for any clarifications.
6 Optional: I would like to meet with Dr. Schmitt first for him to decide what testing, if any, is recommended. Initial here In order to expedite my allergy evaluation, I prefer to commence with allergy skin prick testing before meeting with Dr. Schmitt. I understand that Dr. Schmitt may recommend additional testing that could then be completed. Initial here I would like to have skin prick testing for (please mark any that apply): Complete Environmental Allergen Panel (designed for consideration for allergy shots) Environmental Allergen Screening Panel for adults and children Infant or young child Environmental Allergen Screening Panel Complete Food Allergen Panel Limited Food Allergy Testing only to certain foods (please list): Below for Office Use Only Appointment time: Arrival time: Check-in time: PFT: Y N W H T BP / P R
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit. In order to obtain valid and useful skin testing results, you will need to stop the use of
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1 2 3 4 5 6 Scratch and Sniff All About Allergies Doug Jones, MD Program Director, Family Medicine, DHMG What is an allergic reaction? The immune system identifies things that are foreign and protects
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Please complete and return to the office prior to your appointment.
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Avery Acupuncture & Natural Medicine New Patient Registration
Welcome to Avery Acupuncture & Natural Medicine. Our goal is to make your experience here as comfortable as possible. If you have any questions, comments, concerns or suggestions, please let Veronica or
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:
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Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:
Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Email Address: Emergency Contact Name and Phone Number: Family Doctor Name and Address:
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NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
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Date: Staff only: Weight: Height: BP: Pain Age Patient Name Date of Birth Street Address City State Zip Code Home Phone Work Phone Cell Phone Right handed Left handed Please mark one Referring Physician
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