Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint:
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1 Julie A. Wendt, MD, PLLC N. Scottsdale Rd, Ste 200 Scottsdale, AZ (480) PATIENT HEALTH QUESTIONNAIRE Today s date: Referring Doctor: Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint: How long have you had this problem? How often does it occur? (times per day, week, etc.) How long does it last? (hours, days, etc.) Worse at night or day? Worse inside or outside? Circle the month(s) it is most severe: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec All Year What makes it worse? What makes it better? Have you seen an allergist before? If so, please give details: Are there places you have lived that make the symptoms better or worse? Are there rooms in your house that make your symptoms worse? Where do you work? Are your symptoms better, worse or the same at work? Do any of the following make your symptoms worse? (circle) Heat Cold Exercise Weather changes Dampness Sun Damp basements Raking leaves Barns Cutting grass Hay Drinking wine Drinking beer Eating cheese Sweating Vibration Pressure PAST MEDICAL HISTORY (if YES, please explain) Allergies NO YES: Asthma NO YES: Sinus Problems NO YES: Eczema or other Skin Rash NO YES: Cataracts or Glaucoma NO YES: Thyroid Disease NO YES: Diabetes NO YES:
2 Rheumatoid Arthritis, Lupus NO YES: High Blood Pressure NO YES: Rhythm Disturbance of the Heart NO YES: Other Heart Disease NO YES: Liver Disease NO YES: Kidney Disease NO YES: Blood Clotting Problems NO YES: Prostate Enlargement NO YES: Surgery NO YES: Childhood Illness (chickenpox, measles, etc.) NO YES: Are you pregnant or planning to become pregnant in the near future? NO YES: Other (describe) Last Menstrual Period Hospitalizations or Emergency Room visits within the last 3 years (when and why) Current Medications, non-prescription drugs, and supplements (please note dose, number of times taken per day and start date). For patients with hives, anaphylaxis, drug allergy and angioedema, pleases include length of time. ALLERGY HISTORY Circle the drug(s) which have caused any adverse reaction: Aspirin Nonsteroidal Anti-Inflammatory Drugs (Motrin, Advil, etc.) Nose Sprays Penicillin Sulfa Drugs Other Antibiotics Antihistamines Bronchodilators (Albuterol) Others: What were the symptoms? Foods Nuts: Peanuts Fish: Shellfish: Milk Eggs 2
3 Wheat Soy Other: Mold Wine, Beer Cheese, Mushrooms Damp Basements, humid days, after rain Animals Cats Dogs Horses Insect stings, bites Other: Irritants House dust, dust or powders Fumes Perfumes Smoke Vaccinations (Diphtheria, Tetanus, Pertussis, or Whooping Cough, Polio, Measles, German Measles, Mumps, Influenza, Other) Other Substances Latex Radiocontrast Dye Nickel or other metal: Poison Ivy Other: INFECTION HISTORY Circle if you have had any of the following: Blood Infection Bronchitis Pneumonia Chickenpox Shingles (zoster) Hepatitis HIV or AIDS Meningitis Sinusitis Frequent or Lengthy Ear Infections Frequent or Lengthy Upper Respiratory Tract Infections Tuberculosis or Positive Tuberculin Skin Test Abnormal Chest X-Ray Abnormal Chest CT Scan Abnormal Sinus CT Scan 3
4 FAMILY HISTORY Mother Father Siblings Child Other Hay Fever Other Allergies Asthma Eczema Other SOCIAL HISTORY Do you or have you ever smoked? NO YES Packs per day? How Long? When did you quit? Do you drink alcohol? NO YES How much and how often? Do you have any pets or exposure to animals? NO YES For How long? Do you have (check all that apply: Basement or garden apartment Water leak Flood damage Do you have (check all that apply): Forced air heating Radiator heating Electric heating Other heating Central air conditioning Swamp cooler Fire damage Excess mold or mildew Excess dust Carpet Hardwood floors Other flooring Humidifier De-humidifier Location (circle): Country Suburbs City Farm Other: How long have you lived in your current location? Age of home? REVIEW OF SYMPTOMS Check if any symptoms are currently or recently a problem: General Weight Change Weakness Fatigue Change in alertness Skin Rash Swelling Itching Head Heart Headache Eye itching Runny nose Hoarseness Palpitations Leg swelling Dizziness Eye redness Post nasal drip Sore Throat Skipped or irregular beats Loss of smell Tearing Nose bleeds Bad breath Chest or leg pain during exertion Change in pigment or texture Sinus/facial pain or pressure Eye swelling Nasal congestion Change in gums Beating too fast or too slow 4
5 Lungs GI GU M/S Cough Change in sputum color Heartburn Vomiting Change in urination Joint pain Dry eyes Wheeze Coughing up blood Reflux Diarrhea Blood in urine Stiffness Dry mouth Tightness Shortness of breath, if yes (circle) at rest, with exercise, when asleep Nausea Constipation Difficulty or pain urinating Hemat/Onc Bleeding Bruising Lumps Joint swelling Change in color of fingers in cold Neuro/Psych Depression Anxiety Sleep disturbances Endo Females Change in appetite or thirst Premenopausal Change in skin, hair or nails On birth control pills Postmenopausal Chest pain Abdominal pain Food intolerance Joint redness or heat Unexplained fever or night sweats Is there anything else you d like your doctor to know today? 5
Name: Date: 1. What is the principal reason for consulting us?
Name: Date: 1. What is the principal reason for consulting us? 2. Circle any of the following that you have had: Sneezing Runny nose Stuffy nose Shortness of breath Phlegm Headaches Watery eyes Swelling
New Patient Questionnaire
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Page 1 of 5 Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE NAME: AGE: DATE OF BIRTH: Primary/Referring Physician: Phone #: Other Subspecialists
Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)
Date: How did you hear about us? Patient Name: Internet Physician Referral Date of Birth: Friend Advertisement Patient Email: Referring Physician: Primary Care Physician: _ Age: Reason for visit to allergy
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Name: Date: How were you referred? Physician Other Self Referral. What problem brings you or your child to this appointment?
Name: Date: How were you referred? Physician Other Self Referral What problem brings you or your child to this appointment? What did the symptoms begin? Are your symptoms getting worse? Circle: Yes or
Telephone Number Home: Work: Cell:
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ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR
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Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:
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1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
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Richmond Office 4718 National Rd. E. Richmond, IN
You have an appointment at Allergy & Asthma Care at the following address: Richmond Office 4718 National Rd. E. Richmond, IN 47374 765.966.0390 765.966.3343 You can visit our website at www.allergy-asthmacare.com
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
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General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
MEDICAL HISTORY RECORD
MEDICAL HISTORY RECORD Please print and complete all information. Case. Male Female Medicare. Medicaid. Today s Date Birthdate Last Name First Middle Daytime Phone Home Phone Address City Marital Status
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage