1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.
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1 Patient s Name Date of Appointment Date of Birth Referring Physician 1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment. Briefly describe the reason for your allergy visit and what you hope to accomplish. 2. Problems: Have you ever had the following conditions? Yes No (Check all items that apply) Age of Onset Mild Moderate Severe Comments Asthma (wheezing) Mild Mod. Severe Any Other Breathing Problems Sinus Trouble Hay Fever (Runny, stuffy, itchy nose, sneezing) Hives or Swelling Eczema or Other Rashes Frequent infections Food Reactions Drug Reactions Insect Reactions 3. Symptoms: Have you ever had any of the following? If not, leave blank. How many days In the last month Mild Mod. Severe Circle the Months Most Severe Runny or stuffy nose Itchy nose Sneezing Wheezing Coughing Wheezing or coughing with exercise Skin Problems
2 4. Precipitating Factors / Triggers: For each item below, check the appropriate square to indicate whether you (or your child s) condition is affected by the following triggers. Condition Condition No Made Improved Change Worse Condition Condition No Made Improved Change Worse Cutting or playing in grass, raking leaves, other outdoor exposure. High winds, riding in auto. Moldy / mildewed areas or items Sweeping, dusting or vacuuming Smog, smoking or smoke exposure Air conditioning or heating Cleaning agents, detergents, ammonia, Bleach, soap, conditioner, shaving cream, Toothpaste etc. Specify: Paint, lacquer, glue, mothballs, motor fumes, chemicals, fertilizers, insect spray, cooking Odors, etc. Specify: Other strong odors. Specify; Medications: Antihistamines or cold preparations Asthma medication Nose drops or spray. Aspirin Other Exposure to animals Specify; Colds or viruses Physical exertion or exercise Cold weather Other factors 5. Residence: List all places lived by city and state, approximate dates, effects on your problem. City & State Dates Effect on Symptoms (better, worse, no change) Previous Allergy Evaluation and Therapy Have you ever had allergy skin tests? Yes No if yes, date Results of these tests: (If possible, please provide us with a copy) Physician s Name Have you ever had allergy injections? Yes No If yes, dates
3 7. Medications (Bring all medications with you to your appointment.) Please list all medication that you are currently taking, name, dosage and number of times a day: Please list all medications you have taken for allergies in the past: / Are You Allergic to Any Medications? Please list: 8. Other Medical Problems: Have you ever had any of the following. Answer all items. Yes No Yes No Yes No Frequent Headaches Pneumonia, number past year Liver trouble Frequent Nosebleeds Coughed up blood Frequent Diarrhea Nasal Polyps Tuberculosis Bedwetting Operations on Sinuses Chest X-Ray Poison Ivy or Oak Sinus X-Rays Heart trouble Latex Ear Infections, # in past year High blood pressure Other: Hearing Problems Glaucoma Tonsils / Adenoids (year removed ) Frequent heartburn Diabetes Kidney or bladder trouble 9. Immunizations: ( List dates and reactions, if any) Polio Measles DPT Tetanus Booster Rubella (German Measles) Influenza Other (Pneumonia vaccine, etc.) 10. Hospitalizations / Surgeries List most recent first Reason Date
4 11. Family History Do any members of your family have a history of any of the following? Yes No If yes, list all relatives. (parents, brothers, sisters, children, etc.) Asthma Hay Fever Eczema Hives Swelling Frequent Pneumonia Headaches Other Allergies Is there a family history of any other illnesses? Emphysema or other Lung Disease Cystic Fibrosis Tuberculosis Thyroid Disease Glaucoma Diabetes Other 12. Tobacco Use / Weight Have you ever smoked? Yes No If yes, how many years? Do you presently smoke? Yes No When did you stop? Average cigarettes per day at highest point? Do you want to stop? Yes No Which other members of your household now smoke? Do you use other forms of tobacco (chew, snuff, etc.)? Weight now: Weight one year ago: Maximum weight: When?
5 13. Environmental Survey Where do you live? (city or rural) Type of house (mobile, single family, apt.) Are any rooms damp or musty? Do you have : an air cleaner? Type of heating: Age of house: Number of indoor plants? Raised foundation or slab? An air dehumidifier? Type of air conditioning: Type of flooring in the following rooms (carpet, tile, hardwood, etc.): Bedrooms: Living room: Family room: How old is your pillow? Is your pillow: Feather Encased in plastic Dacron Other Foam rubber How old is your mattress? Type of mattress? Encased? Do you have pets? List number and kind, and how long you have had them? Do your pet spend time indoors? What type of work do you do? Are you exposed to anything at work that might aggravate your condition? Have you missed any time from work or school because of your allergies? Have you missed any time from work or school because of your asthma? Which things? How much time? How much time? Do you have any other exposures from hobbies, recreational activities, etc? Do you have further information you feel is important for us to know?
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Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Asthma & Allergy Clinic REGISTRATION FORM
Asthma & Allergy Clinic REGISTRATION FORM 1 Today s date: Primary Care Provider: Referred by: PATIENT INFORMATION Patient s last name: First name: Middle: Marital status: married divorced widowed separated
! Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique
Head to Heal Family Wellness Centre for Naturopathic Medicine & The Bowen Technique CHILDREN S QUESTIONNAIRE (To be completed by parent/guardian) Date: Child s Name: Mother s/guardian s Name: Mother s/guardian
NEW PATIENT QUESTIONNAIRE
Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
ALLERGY SURVEY SHEET
Roseville 95 Reserve Drive Roseville, CA 95678 Phone: 96.78.7758 Fax: 96.78.7770 Sacramento One Scripps Dr., Suite 05 Sacramento, CA 9585 Phone: 96.95.056 Fax: 96.95.5908 Yuba City 887 Plumas St., Suite
If you have asthma or use a rescue inhaler please answer the following questions:
Hernia (yr ), Tonsillectomy (yr ), Adenoidectomy (yr ), Bowel (yr ), Lung (yr ), Thyroid (yr ), Arthroscopy (yr ), Other Surgery (yr: ) Dates of Hospitalizations: What Hospital: Previous Tests Done/Approximate