List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?
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- Derek Fisher
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1 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? Redness? Fatigue? Puffiness? Shortness of breath Nasal Symptoms Ear Symptoms Nasal Drainage? Itching? Sneezing? Infections? Stuffy nose? Mouth Breathing? Skin Symptoms Itch of the roof of your mouth? Hives? Snoring? Rashes? Sinus Headache? Eczema? Have you had sinus infections? If yes, how often? Do symptoms awaken you at night? If yes, which symptoms and how often? Are you limited in your daily activities? Do you miss days of work/school because of your illness? How many in the last year? Have you gone to the emergency room because of asthma/allergy episodes? frontdesk@allergyandasthmaconsultants.com Page 1 of 6
2 ALLERGY/ASTHMA TRIGGERS Which of the following trigger your symptoms? Certain times of the year? If yes, which times? Open windows? Animals If yes, which ones? Cutting grass? Food? If yes, which ones? House dust/vacuuming? Damp, musty areas? Cold air? Exercise? Irritants? (Perfumes, aerosol sprays, etc.) MEDICAL/ALLERGY TESTING Have you ever had? Chest X-Ray? If yes, date of most recent X-Ray: Sinus X-Ray or CAT Scan of sinuses? If yes, date? Allergy Testing? If yes, date of most recent test: Have you ever taken allergy shots? If yes, how long? When? Pulmonary Function Testing? If yes, date of most recent test: List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often? Page 2 of 6
3 List your other medications, including over-the-counter medications: Medication Dose How Often? Have you ever taken prednisone, cortisone or other steroids (by mouth)? Are you allergic or sensitive to any medications? If yes, which ones? FAMILY HISTORY Do other family members have asthma, sinus problems, or frequent infections? If yes, who? PREGNANCY Are you currently pregnant? Not applicable if male, postmenopausal, or child Are you planning a pregnancy? SMOKING Do you currently smoke? Have you smoked in the past? If yes, for how many years? How much a day? When did you quit? Does anyone in your home smoke? Do you drink alcoholic beverages? If yes, for how many drinks per day? TYPE OF HOME Single family dwelling Apartment Condo Mobile home Age of home: Is there a basement? If yes, is it? Always dry Rarely leaky Frequently leaky Does your basement smell damp or musty? If no basement, is there a? Concrete slab Crawlspace frontdesk@allergyandasthmaconsultants.com Page 3 of 6
4 HEAT/AC Air Conditioning? Window Unit Central Heat? Gas Electrical Radiant Wood Humidifier on furnace? Do you use a fireplace or wood-burning stove? If yes, how often? Do you open windows in mild weather? Do you have an attic fan? BEDROOM Location of bedroom? Basement Ground floor Second floor or above Floor cover in bedroom? Carpet Tile Hardwood Linoleum Other: If carpet, how old? months years Composition, if know: Stuffed animals in bedroom? If yes, how many? Mattress Waterbed Conventional/Fiber-Filled Fiber Content: Age: months years Pillows Fiber Content: Polyester-filled Feather/down Foam rubber Age: months years Do you have a down comforter? ANIMAL/PETS Do you have any? If yes, kind(s) indoor? If yes, kind(s) outdoor? How long have you had the animal(s)? HOUSE PLANTS Do you have any? If yes, how many and type? frontdesk@allergyandasthmaconsultants.com Page 4 of 6
5 MEDICAL HISTORY Have you ever had? Bronchitis? Blood disease? Pneumonia? Anemia? Emphysema? Osteoporosis? Exposure to tuberculosis? Bone fractures? Positive TB skin test? Stomach problems? Other lung disease? Ulcers? Heart Problems? Hernias? Heart Attack? Eye problems? High blood pressure? Cataracts? High Cholesterol? Glaucoma? Diabetes? Seizures? Kidney disease? Have you ever needed oxygen? Liver disease? Have you ever stopped breathing? Cancer? Have you ever been hospitalized? If yes, give reasons and dates: Reason for hospitalization Date Have you ever had surgery? If so, give reasons/procedures, dates: Reason Procedure/s Date Page 5 of 6
6 PEDIATRIC PATIENTS ONLY Length of pregnancy? months Were there problems during pregnancy, delivery, or newborn period? If yes, please explain: Birth weight? lbs. oz. Has your child had chicken pox? Has your child had RSV? Are your child s immunizations up to date? RESEARCH STUDIES Dr. Onder and Allergy and Asthma Consultants, P.C. conduct clinical research studies on new allergy and asthma medications. Would you be interested in you or your child participating in studies of new medications? Maybe frontdesk@allergyandasthmaconsultants.com Page 6 of 6
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
Allergy/Immunology Questionnaire
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Telephone Number Home: Work: Cell:
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Name: Date: 1. What is the principal reason for consulting us?
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Laser Vein Center Thomas Wright MD Page 1 of 4
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Asthma. The prevalence of asthma has been increasing worldwide, but why this is happening is not known.
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UnityPoint Clinic - Cardiology
UnityPoint Clinic - Cardiology Date Completed: Appointment Date: Name: Age: Birthdate: / / FIRST MIDDLE INITIAL LAST Referred by: Family Dr.: Reason for visit: Describe briefly, include date of onset:
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Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
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REVIEWED DATE / INITIALS Safety: Yes No Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: Yes No If YES, please list medication allergies:
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PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
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