(pedi) Patient Name: date of birth:

Size: px
Start display at page:

Download "(pedi) Patient Name: date of birth:"

Transcription

1 (pedi) Patient Name: date of birth:_ Date: I am being seen on: a) self referral _ b) physician referral from Dr. Please share the main reasons for your office visit today (check all those that apply): a) Allergic rhinitis (runny and/or stuffy nose) e) Atopic dermatitis (eczema) _ b) Allergic conjunctivitis (red, itchy eyes) f) Nasal polyps _ c) Asthma g) Urticaria (hives) _ d) Bronchitis h) Frequent sinus infections _ i ) Other What you would like to accomplish today? a) Review my current illness and treatment b) Obtain allergy testing c) Obtain information on asthma diagnosis and treatment d) Other _ HISTORY OF PRESENT ILLNESS (please fill in all sections which apply to you or your family member): My symptoms began : My symptoms are: days ago Seasonal: (Worse during a certain season? Check which season is worse) weeks ago Spring months ago Summer years ago Fall Winter Perennial (equal all year) with no seasonal change Perennial (equal all year) with seasonal exacerbations in the: Spring Summer Fall Winter Please check which of the following symptoms are present: NOSE: EYES: Nasal congestion (blockage) Redness: Mouth breathing at night: Watering: Itchy nose: Sensitivity to light: Bloody nose: Itching: Sneezing: Snoring: HEADACHE: Poor sense of smell: Location (front, side, back) Drippy/runny nose: Quality (sharp, dull, achy) Drainage in back of throat: EARS: LUNGS: Itching: Shortness of breath: Frequent infections: Wheezing: Congestion (stuffiness) Cough: SKIN: Hives: Eczema: Swelling of face:

2 Triggers that I know worsen my symptoms include: 2 No known environmental triggers _ Non-specific environmental triggers: Specific environmental triggers: Weather changes Indoor dust: _ any weather change Outdoor dust: _ hot and dry weather Mold spores: _ cold and wet weather Animal dander Tobacco exposure cat Perfumes and propellants dog Other other All pollens tree pollen grass pollen weed pollen other pollen ALLERGY HISTORY: Allergy testing has: I have never been on allergy injections never been pursued I am currently on allergy injections is scheduled These began months ago has previously shown years ago no allergies allergy to: I previously received allergy injections pollen These were given years ago dust I continued these for years mold pets other _ Have you had experience with any of the following medications? If so, did they help? TYPE OF MEDICATION RESULT EXAMPLES (i.e., Claritin, Flonase, etc.) GOOD BAD Antihistamines Decongestants Antihistamine/Decongestants Nose sprays Eye drops Have you had allergic reactions to medications or foods? DRUG REACTIONS: Name of medication Type of reaction (skin, respiratory, stomach symptoms, etc.) 1) 2) 3) FOOD REACTIONS Name of food Type of reaction 1) 2) 3)

3 PAST MEDICAL HISTORY 3 Hospitalizations and/or surgery: Age or year for Other chronic health conditions (Please specify) Please list all of your current medications: Name of medication Route, dose & frequency Indication (i.e., 10mg each morning) (i.e., for blood pressure) 1) 2) 3) 4) 5) FAMILY HISTORY (Please check if your family member is or has been affected by the following illnesses): Asthma or Allergic rhinitis Atopic dermatitis Urticaria Chronic bronchitis (hayfever) (eczema) (hives) Mother Father Brother Sister Other relatives SOCIAL HISTORY: Parents marital status Married Separated lives with mother lives with father other _ Divorced lives with mother lives with father joint custody other _ Members of household mother father brother(s) (how many) sister(s) (how many) other(s)

4 Name of daycare/school Grade level/classification _ daycare/preschool grade school middle school high school 4 Extracurricular activities/hobbies: Employment (if applicable): sports where band/choir/orchestra position cheerleading 4-H other _ TOBACCO HISTORY: Cigarette smoker/or exposure (check all that apply): Exposure to cigarette smoke _ Non smoker Smoker Ex-smoker quit how long ago weeks _ months _ years _ pack/day for _ years _ Other tobacco use ENVIRONMENTAL HISTORY: The patient lives in a(n): house apartment other _ The home is in: town the country other Indoor exposure to the following is present: Pets: Heating/Air-conditioning: cats _ central heat/air dogs _ evaporative cooler other gas heat/furnace other Bedding: boxspring mattress waterbed other _ Carpeting in bedroom

5 ASTHMA (Please skip this page if you have never had breathing problems) Asthma has: never been previously diagnosed, but is suspected _ been diagnosed in childhood _ at age been diagnosed in adulthood _ at age My compliance with medications: I currently use the following: is always excellent a spacer attached to my inhaler is intermittently good a peak flow meter to measure breathing is poor because: a written asthma action plan I hate to take any medication I am concerned about side effects medications are too expensive medications have not helped me in the past other Triggers for my asthma symptoms include: no obvious exposures pollens cigarette smoke sinus infections animal dander weather change exercise dust respiratory infections/colds other Asthma medications I have had previous experience with include: ASTHMA RELIEVERS Response Quick-acting Good Bad Leukotriene modifiers (cont d) Good Bad Albuterol Zyflo Xopenex Mast cell stabilizers Maxair Intal Atrovent Tilade Combivent Combination drugs Long-term Advair Foradil Symbicort Serevent Theophylline ASTHMA CONTROLLERS Slo-Bid Inhaled steroids UniDur Aerobid Uniphyl Azmacort Oral Steroids Beclovent Prednisone Flovent Medrol Pulmicort Prelone Vanceril Pediapred Leukotriene modifiers Other medications Singulair Accolate

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):

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): NAME: AGE: ---- Date of Appointment:. ID (For Office Use Only): RETURN VISIT Date of Visit: Main Reason for visit: Reevaluation Family Doctor: Symptoms worse _ New problem _ Yearly follow up _ Follow up/office

More information

Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:

Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician: Dr. Bina Joseph Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician: Describe each problem that has led you to seek this allergy evaluation: 1. 2. 3. 4. Drug Allergies:

More information

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. 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

More information

PLEASE DO NOT WEAR FRAGRANCES

PLEASE DO NOT WEAR FRAGRANCES Patient s Name: City: State: Zip: Male Female Race: Ethnicity: Language 1st: 2nd: Home Phone: Work Phone: Cell Phone: Email: Occupation: Employer: City: State: Zip: Family Doctor/Pediatrician: City: State:

More information

Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco

Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco 180 Montgomery Street, Suite 2370 San Francisco, CA 94104 Tel: (415) 433-6673 Fax: (415) 433.6063 www.mydrd.com Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor,

More information

Medical History Form

Medical History Form Dr. Vivek U. Rao, M.D. 500 Adams Ave., Suite 300 Odessa, TX 79761 Phone: 432.333.3300 Fax: 432.339.3300 Medical History Form Patient Name: DOB: A. CHIEF COMPLAINT: Briefly describe your (or your child

More information

Allergy/Immunology Questionnaire

Allergy/Immunology Questionnaire Anita Shvarts, M.D. 85 Seasons Lane Hiawassee, GA 30546 [p] 855.656.6673 [f] 877.811.4836 Allergy/Immunology Questionnaire Please take a moment to complete this form. It will help the practitioner better

More information

ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:

ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE: ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE: A. Please check any of the following problems which you have had, and record when they started: Problem/Date of Onset sniffles nasal congestion

More information

Pediatric and Adult Asthma, Allergy & Immunology. New Patient Forms

Pediatric and Adult Asthma, Allergy & Immunology. New Patient Forms Pediatric and Adult Asthma, Allergy & Immunology New Patient Forms PLEASE READ Completing these forms in advance of your visit can save you significant time in the waiting room and during your visit. It

More information

New Patient Questionnaire

New Patient Questionnaire - - Toda y 's Date: Primary Care Provider's Name: Was a consultation recommended? Primary Clinic: Referring provider's name (if different): Please answer the following questions to facilitate the diagnosis

More information

Telephone Number Home: Work: Cell:

Telephone Number Home: Work: Cell: Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST

More information

Name: Date: 1. What is the principal reason for consulting us?

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

More information

Staying Healthy. with Asthma. Illustrations by paulsharp.com

Staying Healthy. with Asthma. Illustrations by paulsharp.com Staying Healthy with Asthma Illustrations by paulsharp.com Lungs & Asthma What is Asthma? Inflammation or swelling of airways that leads to: 1) Mucous production deep inside the airways. 2) Temporary difficulty

More information

ASTHMA CONTROL. Asthma is a chronic airway disease. You cannot cure asthma, but you can control it. Treatment can improve asthma symptoms.

ASTHMA CONTROL. Asthma is a chronic airway disease. You cannot cure asthma, but you can control it. Treatment can improve asthma symptoms. ASTHMA CONTROL Asthma is a chronic airway disease. You cannot cure asthma, but you can control it. Treatment can improve asthma symptoms. Asthma changes the lung airways in 3 ways: 1. Lining of the airways

More information

Jagdeep Hundal, MD, Otolaryngology, Head & Neck Surgery 774 Christiana Rd, Suite B4, Newark, DE Phone: Fax:

Jagdeep Hundal, MD, Otolaryngology, Head & Neck Surgery 774 Christiana Rd, Suite B4, Newark, DE Phone: Fax: Allergy Questionnaire Patient Name Date / / 1. What symptoms do you suffer from? Please circle below Eyes: Itchy eyes, tearing, eye redness, eye discharge Ears: Popping sensation, fullness, itching Nose/Sinus:

More information

Asthma medications: Know your options - MayoClinic.com. Asthma medications: Know your options

Asthma medications: Know your options - MayoClinic.com. Asthma medications: Know your options MayoClinic.com reprints This single copy is for your personal, noncommercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, use the reprints

More information

Nancy Davis, RRT, AE-C

Nancy Davis, RRT, AE-C Nancy Davis, RRT, AE-C Asthma Statistics 25.6 million Americans diagnosed with asthma 6.8 million are children 10.5 million missed school days per year 14.2 lost work days for adults Approximately 10%

More information

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure Allergy is a condition in which the immune system causes sneezing, itching, rashes, and wheezing, or sometimes even life-threatening allergic reactions. The more you know about allergies, the better prepared

More information

LEARN ABOUT ANOTHER WAY TO TREAT YOUR ALLERGIES

LEARN ABOUT ANOTHER WAY TO TREAT YOUR ALLERGIES LEARN ABOUT ANOTHER WAY TO TREAT YOUR ALLERGIES WHAT ARE ALLERGIES? It s probably not something that you think about, but every time you open your mouth or inhale, tiny particles from the environment that

More information

Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE

Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE 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

More information

1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment.

1. Instructions: Please answer the questions as they relate to the person being evaluated. Bring this form with you to your first appointment. 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.

More information

BOULDER MEDICAL CENTER, P.C.

BOULDER MEDICAL CENTER, P.C. BOULDER MEDICAL CENTER, P.C. Dear Patient, We are pleased that you have chosen our clinic for your medical needs. Here are a few suggestions to make your visit with us a pleasant experience. Please arrive

More information

List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?

List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often? NEW PATIENT HISTORY Patient s Name: Last First Middle Age: Primary Care or Referring Physician: Name Address Please check Yes or No: Symptoms Eye Symptoms Cough? Itching? Wheeze? Watering? Tight Chest?

More information

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? 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

More information

Please Print When Filling Out This Form

Please Print When Filling Out This Form Please Print When Filling Out This Form For Office Use Only Patient #: Location: Date of First Appointment: Patient Information Patient s Name: Home: ( ) Address: _ Street City State Zip E- Mail Address:

More information

SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE

SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE BRIEFLY DESCRIBE REASON FOR ALLERGY VISIT. HAVE YOU EVER HAD THE FOLLOWING S: PRESENT PROBLEM YES

More information

Asthma By Mayo Clinic staff

Asthma By Mayo Clinic staff MayoClinic.com reprints This single copy is for your personal, noncommercial use only. For permission to reprint multiple copies or to order presentation-ready copies for distribution, use the reprints

More information

ASTHMA IN THE PEDIATRIC POPULATION

ASTHMA IN THE PEDIATRIC POPULATION ASTHMA IN THE PEDIATRIC POPULATION SEARCH Rotation 2 August 23, 2010 Objectives Define asthma as a chronic disease Discuss the morbidity of asthma in pediatrics Discuss a few things that a health center

More information

Ear, Nose & Throat (ENT) - Head & Neck Surgery. Allergic Rhinitis (Sinus)

Ear, Nose & Throat (ENT) - Head & Neck Surgery. Allergic Rhinitis (Sinus) Ear, Nose & Throat (ENT) - Head & Neck Surgery Allergic Rhinitis (Sinus) The Department of Ear, Nose & Throat (ENT) - Head & Neck Surgery provides a wide range of surgical services for adult patients with

More information

Does rhinitis. lead to asthma? Does sneezing lead to wheezing? What allergic patients should know about the link between allergic rhinitis and asthma

Does rhinitis. lead to asthma? Does sneezing lead to wheezing? What allergic patients should know about the link between allergic rhinitis and asthma Does rhinitis lead to asthma? Does sneezing lead to wheezing? What allergic patients should know about the link between allergic rhinitis and asthma For a better management of allergies in Europe Allergy

More information

ALLERGY QUESTIONNAIRE. Patient Name

ALLERGY QUESTIONNAIRE. Patient Name ALLERGY QUESTIONNAIRE Patient Name_ DOB: _ What problem brings you to this appointment? When did symptoms begin? Please check all symptoms that apply. NOSE Runny Nose Nasal Congestion Itchy Nose Postnasal

More information

MANAGING ASTHMA. Nancy Davis, RRT, AE-C

MANAGING ASTHMA. Nancy Davis, RRT, AE-C MANAGING ASTHMA Nancy Davis, RRT, AE-C What is asthma? Asthma is a chronic respiratory disease characterized by episodes or attacks of inflammation and narrowing of small airways in response to asthma

More information

Glossary of Asthma Terms

Glossary of Asthma Terms HealthyKidsExpress@bjc.org Asthma Words to Know Developed in partnership with Health Literacy Missouri Airways (Bronchi, Bronchial Tubes): The tubes in the lungs that let air in and out of the body. Airway

More information

9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY

9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY Name: Date of Birth: Date of Visit: Briefly describe the reason for your visit: How long have you had these problems? How frequently do you have them? NASAL SYMPTOMS ALLERGY HISTORY 1. I have the following

More information

ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR

ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR Name D.O.B. Date Reason for your visit today: Please put a check and complete the blanks which apply to your symptoms: Present Problem Past Problem

More information

Your child s name: Today s Date: When was your child s last asthma visit?. If your child has never had an asthma visit, check here:

Your child s name: Today s Date: When was your child s last asthma visit?. If your child has never had an asthma visit, check here: Communicate with Your Child s Doctor about His / Her Asthma Asthma also includes reactive airway disease, regular coughing, wheezing, or difficulty breathing with or without colds. Your child s name: Today

More information

Pediatric Allergy Allergy Related Testing

Pediatric Allergy Allergy Related Testing Pediatric Allergy Allergy Related Testing 1 Allergies are reactions that are usually caused by an overactive immune system. These reactions can occur in a variety of organs in the body, resulting in conditions

More information

Why does the body develop allergies?

Why does the body develop allergies? Allergies & Hay Fever Millions of Americans suffer from nasal allergies, commonly known as hay fever. Often fragrant flowers are blamed for the uncomfortable symptoms, yet they are rarely the cause; their

More information

Richmond Office 4718 National Rd. E. Richmond, IN

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

More information

Asthma. January 2011

Asthma. January 2011 Asthma January 2011 What is Asthma? Asthma is a lung disease that affects the breathing tubes (airways) that allow air to go in and out of the lungs. Normal airways are wide open, so air can go in and

More information

allergic rhinitis 3C47E65837E D1B E Allergic Rhinitis 1 / 6

allergic rhinitis 3C47E65837E D1B E Allergic Rhinitis 1 / 6 Allergic Rhinitis 1 / 6 2 / 6 3 / 6 Allergic Rhinitis Allergic rhinitis is a diagnosis associated with a group of symptoms affecting the nose. These symptoms occur when you breathe in something you are

More information

PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME

PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME FOR OFFICE USE ONLY PATIENT NO. PLEASE RETURN THIS FORM TO ARKANSAS ALLERGY & ASTHMA CLINIC, P.A. OR BRING IT WITH YOU TO YOUR FIRST APPOINTMENT PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME AGE: Who is

More information

1

1 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

More information

Allergies and Asthma 5/21/2013. Objectives. Allergic Rhinitis (AR): Risk Factor for ASTHMA. Rhinitis and Asthma

Allergies and Asthma 5/21/2013. Objectives. Allergic Rhinitis (AR): Risk Factor for ASTHMA. Rhinitis and Asthma Allergies and Asthma Presented By: Dr. Fadwa Gillanders, Pharm.D Clinical Pharmacy Specialist May 2013 Objectives Understand the relationship between asthma and allergic rhinitis Understand what is going

More information

What are Allergy shots / SCIT?

What are Allergy shots / SCIT? Allergy diagnosis must be made accurately with correct history and tests including the skin prick test and the blood test like immunocap / Phadiatop study. This once made will help decide the dose and

More information

Breathe Easy. Living with Asthma

Breathe Easy. Living with Asthma Breathe Easy Living with Asthma Got Asthma? You re Not Alone! More than 300 million people around the world have asthma. But having asthma doesn t have to limit what you can do. With education and treatment,

More information

Allina Health United Lung and Sleep Clinic

Allina Health United Lung and Sleep Clinic Medical History Form Date Allina Health United Lung and Sleep Clinic Name Last First MI Date of birth What lung problem do you want us to help you with: Who is your primary care provider? Social History

More information

Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F

Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F Comprehensive Allergy and Asthma Care Center New Patient Questionnaire Patient Name: Age: DOB: Sex: M F Primary Physician (Name, Address and Phone Number): Do you want the allergy consultation note sent

More information

Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present

Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present BRIEFLY DESCRIBE THE REASON FOR THIS VISIT (what is your main concern or symptom?): CHECK SYMPTOMS YOU HAVE OR HAVE HAD: Nasal Symptoms Past Present Nasal congestion Runny nose Nasal discharge Postnasal

More information

Ailléirge Péidiatraiceach. Pediatric Allergy 3/9/2018. Disclosures & Conflicts Of Interest

Ailléirge Péidiatraiceach. Pediatric Allergy 3/9/2018. Disclosures & Conflicts Of Interest Ailléirge Péidiatraiceach Michael Zacharisen, M.D. Allergy/Immunology Pediatric Allergy Michael Zacharisen, M.D. Allergy/Immunology Disclosures & Conflicts Of Interest Green Bay Packer fan I drive a Jeep

More information

Breathe Easy ACTIVITIES. A Family Guide to Living with Asthma F O R T H E K ! I D S

Breathe Easy ACTIVITIES. A Family Guide to Living with Asthma F O R T H E K ! I D S Breathe Easy A Family Guide to Living with Asthma ACTIVITIES FUN & EDUCATIONAL F O R T H E K! I D S What Is Asthma? Asthma is a disease of the lungs. It s a chronic (long-term) condition that affects the

More information

Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)

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

More information

Initial Allergy Questionnaire and History

Initial Allergy Questionnaire and History Initial Allergy Questionnaire and History No Antihistamines for 72 hours prior to Testing appointments Your Appointment is on: DATE: TIME: WITH: Jean Carney, MD Kuo Casey Chang, MD Austin Sargent, MD,

More information

Initial Allergy Questionnaire and History

Initial Allergy Questionnaire and History Initial Allergy Questionnaire and History Your Appointment is on: DATE: TIME: WITH: Michael Barrett, MD Office: No Antihistamines for 72 hours prior to Testing appointments Kuo Casey Chang, MD Erica Bocchi,

More information

Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER?

Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER? Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER? Hay Fever is the most common type of seasonal allergies experienced by the

More information

Patient Name: Date / Time of Appt: at

Patient Name: Date / Time of Appt: at 12422 South 450 East, Suite C, Draper, UT 84020 (801) 553-1900 Fax (801) 553-9995 Patient Name: Date / Time of Appt: at Duane J. Harris, MD and the staff of Intermountain Allergy & Asthma of Draper welcome

More information

Date of Birth Sex: M or F Age

Date of Birth Sex: M or F Age MEDICAL HISTORY FORM For Office Use Only Pt# HT WT BP HR RR 500 South University Suite 215 Little Rock, AR 72205 Phone 501-420-1085 Fax 501-420-1457 Patient Name: Last First Middle Initial Date of Birth

More information

Amy R. Ellingson, M.D. Laura Fouquette, PA-C

Amy R. Ellingson, M.D. Laura Fouquette, PA-C Allergy & Asthma Specialty Clinic 1037 19 th Ave SW PO Box 1015 Willmar, MN 56201 Phone: 320-214-1100 Fax: 320-214-1155 Toll Free: 1-877-866-ITCH (4824) www.willmarallergy.com Amy R. Ellingson, M.D. Laura

More information

New Patient Registration

New Patient Registration 1 New Patient Registration Please Print New Patient Name (Last, First, Middle ) Nickname Maiden / Former Name Male / Female Single / Married / Divorced / Widowed Age Date of Birth Social Security Number

More information

ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #200 MAPLE GROVE, MN TEL (763) FAX (763)

ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #200 MAPLE GROVE, MN TEL (763) FAX (763) DATE: ALLERGY AND ASTHMA CARE, P.A. 12000 ELM CREEK BLVD. #200 MAPLE GROVE, MN 55369 TEL (763) 420-1010 FAX (763) 420-3710 LEGAL NAME: Last First Middle Initial ADDRESS: Street City State Zip Code DATE

More information

The Impact of Hay Fever - a survey by Allergy UK PART 1

The Impact of Hay Fever - a survey by Allergy UK PART 1 The Impact of Hay Fever - a survey by Allergy UK PART 1 Supported and funded by HayMax April 2016 Foreword The role of Allergy UK, is to support the needs and concerns of those with allergies and intolerances.

More information

Mr. Ms. Mrs. Dr. First MI Last. Zip City State. Zip City State. Zip City State. Zip City State. Mr. Ms. Mrs. Dr. DOB: First MI Last.

Mr. Ms. Mrs. Dr. First MI Last. Zip City State. Zip City State. Zip City State. Zip City State. Mr. Ms. Mrs. Dr. DOB: First MI Last. 1 of 14 2 of 14 3 of 14 Date / / History No.: Patient Information Street Mr. Ms. Mrs. Dr. First MI Last Mailing Phone Date of Birth SS# Occupation Gender M F Marital Status Employer Employer Phone Family

More information

P R E S E N T S Dr. Mufa T. Ghadiali is skilled in all aspects of General Surgery. His General Surgery Services include: General Surgery Advanced Laparoscopic Surgery Surgical Oncology Gastrointestinal

More information

What are the causes of nasal congestion?

What are the causes of nasal congestion? Stuffy Noses Nasal congestion, stuffiness, or obstruction to nasal breathing is one of the oldest and most common human complaints. For some, it may only be a nuisance; for others, nasal congestion can

More information

THE ALLERGY AND ASTHMA CLINIC

THE ALLERGY AND ASTHMA CLINIC THE ALLERGY AND ASTHMA CLINIC ANDREW C. ENGLER, M.D. JUNE Y. ZHANG, M.D. BROOKE LEON, N.P. ELISABETH DENKER, N.P. Date: *Please plan on spending 2 hours at this first visit. Dear, We are looking forward

More information

Asthma in Pregnancy. Asthma. Chronic Airway Inflammation. Objective Measures of Airflow. Peak exp. flow rate (PEFR)

Asthma in Pregnancy. Asthma. Chronic Airway Inflammation. Objective Measures of Airflow. Peak exp. flow rate (PEFR) Chronic Airway Inflammation Asthma in Pregnancy Robin Field, MD Maternal Fetal Medicine Kaiser Permanente San Francisco Asthma Chronic airway inflammation increased airway responsiveness to a variety of

More information

Breath of Fresh Air. for the health of the nation, stated in Healthy People 2010,

Breath of Fresh Air. for the health of the nation, stated in Healthy People 2010, Volume 7, No. 4 Spring 2003 Asthma Trends in the United States In 1996, when asked During the past 12 months, have you had asthma?, 14.6 million Americans responded yes on behalf of themselves or their

More information

Derriford Hospital. Peninsula Medical School

Derriford Hospital. Peninsula Medical School Asthma and Allergic Rhinitis iti What is the Connection? Hisham Khalil Consultant ENT Surgeon Clinical Senior Lecturer, PMS Clinical Sub-Dean GP Evening 25 June 2008 Plymouth Derriford Hospital Peninsula

More information

Asthma. The prevalence of asthma has been increasing worldwide, but why this is happening is not known.

Asthma. The prevalence of asthma has been increasing worldwide, but why this is happening is not known. Asthma What is asthma? Asthma is a chronic disorder of the airways of the lungs. The airways are reactive and may be inflamed even when symptoms are not present. The extent and severity of airway irritation

More information

your triggers? Information about a simple lab test that lets you Know Your IgE.

your triggers? Information about a simple lab test that lets you Know Your IgE. What your are CAT DANDER DUST MITE triggers? Knowing if you have allergic triggers can help you manage your symptoms. Know yours and take control. OAK Information about a simple lab test that lets you

More information

NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician:

NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician: Patient s Name: NEW PATIENT HISTORY Last First Middle Age: Primary Care or Referring Physician: Name How do you hear about our office? Referred by physician: (name): Referred by family or friend Facebook

More information

Kickin Asthma. Workbook for Children with Asthma. Name:

Kickin Asthma. Workbook for Children with Asthma. Name: Kickin Asthma Workbook for Children with Asthma Name: Why Have You Been Invited to Kickin Asthma? You have been invited to Kickin Asthma because you have asthma. Asthma is a disease of your air tubes that

More information

SN E E Z E S A N D W H E E Z E S

SN E E Z E S A N D W H E E Z E S SN E E Z E S A N D W H E E Z E S Volume 1, Issue 6 March/April 2008 Tree Pollen Springs into Action!! Inside this Issue Allergy and Asthma information 2-3 Ask the Doctor/ Experts (FAQ s) 4 Office Hours

More information

THE ALLERGY AND ASTHMA CLINIC

THE ALLERGY AND ASTHMA CLINIC THE ALLERGY AND ASTHMA CLINIC ANDREW C. ENGLER, M.D. JUNE Y. ZHANG, M.D. BROOKE LEON, N.P. ELISABETH DENKER, N.P. *Please plan on spending at least 2 hours at this first visit. Date: Dear, We are looking

More information

Allergy Clinic of Iowa Advanced Allergy Therapeutics

Allergy Clinic of Iowa Advanced Allergy Therapeutics 1 Name: Address: City: State: Zip: Phone: Email: Date of Birth: Male Female Pregnant Yes No Trimester 1 2 3 SECTIONS: Please select the section(s) that apply to you and complete those sections only 1.

More information

Asthma and IAQ. Lani Wheeler, MD, Medical Officer Sarah Merkle, MPH, Program Analyst

Asthma and IAQ. Lani Wheeler, MD, Medical Officer Sarah Merkle, MPH, Program Analyst Asthma and IAQ Lani Wheeler, MD, Medical Officer Sarah Merkle, MPH, Program Analyst Division of Adolescent and School Health Centers for Disease Control and Prevention Asthma is a Major Public Health Problem

More information

Provider Respiratory Inservice

Provider Respiratory Inservice Provider Respiratory Inservice 2 Welcome Opening Remarks We will cover: Definition of Asthma & COPD Evidence based guidelines for diagnosis, evaluation, and management of asthma Evidence based guidelines

More information

Clinical Implications of Asthma Phenotypes. Michael Schatz, MD, MS Department of Allergy

Clinical Implications of Asthma Phenotypes. Michael Schatz, MD, MS Department of Allergy Clinical Implications of Asthma Phenotypes Michael Schatz, MD, MS Department of Allergy Definition of Phenotype The observable properties of an organism that are produced by the interaction of the genotype

More information

Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year

Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year 500 South University Suite 215 Little Rock, AR 72205 Phone 501-420-1085 Fax 501-420-1457 Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year How did you hear about our clinic? (Check

More information

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them.

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. Asthma s It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them. With asthma, your child s airways are very sensitive. Things, called triggers, may

More information

Your Child and Asthma

Your Child and Asthma Understanding Your Child and Asthma An educational health series from Our Mission since 1899 is to heal, to discover, and to educate as a preeminent healthcare institution. We serve by providing the best

More information

Cold, Flu, or Allergy?

Cold, Flu, or Allergy? A monthly newsletter from the National Institutes of Health, part of the U.S. Department of Health and Human Services October 2014 Cold, Flu, or Allergy? Know the Difference for Best Treatment You re feeling

More information

Children s Web-based Questionnaire

Children s Web-based Questionnaire Children s Web-based Questionnaire Lungehelseundersøkelsens Generasjonsstudie (Norwegian title used for ethics application translated «The lung health investigation s Generation Study Name chosen in order

More information

ASTHMA & ALLERGY CENTER

ASTHMA & ALLERGY CENTER ASTHMA & ALLERGY CENTER Parkersburg. Ripley.Beckley.Logan. CHARLESTON. WV 25314 Asthmaweb,com 30344300 Welcome All of us at the Asthma and Allergy Center would like to welcome you as a new patient to our

More information

Home Management Plan. Cover Page

Home Management Plan. Cover Page Home Management Plan Cover Page What is Asthma? Asthma is a chronic disease of the lungs caused by swelling and irritation in the lining of airways Tightness of the airway muscles Excess mucus in the airways

More information

Allergic Rhinitis: When to Refer to an Allergist

Allergic Rhinitis: When to Refer to an Allergist Allergic Rhinitis: When to Refer to an Allergist Kirsten Kloepfer, MD, MS Assistant Professor of Pediatrics Section of Pulmonary, Allergy and Sleep Medicine Disclosures NIH K23 American Academy of Allergy,

More information

Asthma Education. The Keys to Asthma Prevention and Control. what to do when one s asthma is flared! Lucile Packard Children s Hospital.

Asthma Education. The Keys to Asthma Prevention and Control. what to do when one s asthma is flared! Lucile Packard Children s Hospital. Asthma Education Lucile Packa r d Children s H o spit al Created by Rachel Lawler RN, MSN, cpnp, AE-C, NPAT Pulmonary Pediatric Nurse Practitioner Lucile Packard Children s Hospital The Keys to Asthma

More information

ALLERGY & ASTHMA ASSOCIATES PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS THE PAPERWORK - BRING ALL INSURANCE CARDS

ALLERGY & ASTHMA ASSOCIATES PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS THE PAPERWORK - BRING ALL INSURANCE CARDS ALLERGY & ASTHMA ASSOCIATES Harold Kreithen, M.D. Neil Feldman, D.O. Candace Kubek, C.R.N.P. This is to confirm your appointment on: Location: PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS

More information

Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs

Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs HEALTH QUESTIONNAIRE Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs Patient s Name: Date of Birth: Date of Appointment: INSTRUCTIONS: Please

More information

Allergy overload. Nip those springtime allergies in the bud

Allergy overload. Nip those springtime allergies in the bud Y Name: VIBE ACTIVITIES E A R Issue 199 Years Healthy Vibe Healthy Body Allergy Overload page 26 Allergy overload Nip those springtime allergies in the bud W inter s over... the jumpers and trackies go

More information

Web E-Mial Registration Form. Med practitioner s name. Med practitioner s phone. Name/location of the clinic

Web  E-Mial Registration Form. Med practitioner s name. Med practitioner s phone. Name/location of the clinic AsthmaCare Program Buteyko Clinic USA, LLC Web www.asthmacare.us E-Mial info@asthmacare.us Workshop Date Workshop location Registration Form The purpose of this form is to assist AsthmaCare practitioner

More information

Allergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION

Allergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION 720 W. 34 th Street Suite 200 Austin, Texas 78705 Office (512) 454-5821 Fax (512) 459-9137 PATIENT INFORMATION MRN DR ENTERED VERIFIED Patient Information ( as it appears on insurance card) Last First

More information

The British Allergy Foundation For more information on hay fever and other allergies, you can contact:-

The British Allergy Foundation   For more information on hay fever and other allergies, you can contact:- Sources: Asthma UK The British Allergy Foundation www.prodigy.nhs.uk www.nhsdirect.nhs.uk 2006 Review 2007 March 2008 For more information on hay fever and other allergies, you can contact:- Allergy UK,

More information

ASTHMA INFORMATION SHEET

ASTHMA INFORMATION SHEET ASTHMA INFORMATION SHEET Name of student Name of parent/guardian School Year Grade Asthma Management Date or age of diagnosis Name of current physician Office number Please list ALL current medications,

More information

(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most?

(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most? 6801 S. Yosemite St. Centennial, CO 80112 3260 E. 104th Ave. Thornton, CO 80233 18620 Green Valley Ranch Blvd. Suite 101 Denver, CO 80249 1551 Professional Ln. Longmont, CO 80501 Office: 303.773.9000 Fax:

More information

Foundations of Pharmacology

Foundations of Pharmacology Pharmacologic Management of Asthma Objectives: 1. Review the physiological basis for asthma therapy 2. Discuss the differences between SABA and LABA 3. Discuss the role of inhaled and oral systemic corticosteroids

More information

Most common chronic disease in childhood Different phenotypes:

Most common chronic disease in childhood Different phenotypes: Dr. W. Wijnant Paediatric Pulmonology Steve Biko Academic Hospital Most common chronic disease in childhood Different phenotypes: Viral wheezer Multiple trigger wheezer Transient wheezer Persistent early

More information