If you have asthma or use a rescue inhaler please answer the following questions:

Transcription

1 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 Dates/Where/Results: Chest X-Ray: ph Probe: Sinus CT: Barium swallow: Bronchoscopy: Immunoglobin studies: Sweat Chloride: Methacholine Studies: Rhinoscopy: Pulmonary Function Studies: Date of most recent Flu Shot: Pneumococcal Vaccine: If you have asthma or use a rescue inhaler please answer the following questions: Please circle all asthma symptoms that apply: Cough, wheezing, coughing up blood, sudden attacks of shortness of breath, shortness of breath at rest, shortness of breath with activity, shortness of breath at night, sputum production, chest tightness, other. Asthma Severity: Check One That Most Applies: Symptom frequency <1x/week 2-6x/week daily always

2 Nighttime asthma symptom frequency <2x/month 2-4x/month 2-4x/week almost every night Do asthma symptoms wake you up at night Never Sometimes Usually Always Do you have asthma attacks after physical activity Never Sometimes Usually Always Do your symptoms interfere with school or work? Never Sometimes Usually Always Do your symptoms go away after the use of an inhaler? No Yes(which inhaler) How often do you use extra inhaler treatments? Never Sometimes 2-5x/week Daily Do you have frequent asthma episodes? No Yes Have your symptoms forced you to change your occupation or quit work? No Yes Have your symptoms required frequent trips to the Emergency Room? No Yes Have your symptoms resulted in any hospitalizations? No Yes Have your symptoms resulted in respiratory arrest, intubation or the use of a mechanical ventilator? No Yes Trigger Factors Circle all triggers that cause a worsening of your respiratory condition? Bronchitis Colds/Flu Sinus Infections Non-steroidal anti-inflammatory (Ibuprofen, Aspirin, Naproxen) Exercise Wines, Alcohol Cigarette Smoke Perfumes Hair Sprays Dogs Cats Other animals Foods Food Additives Laughter Damp Musty areas Weather changes Occupational exposures Pollens Cold Air Air Pollution House Dust/Vacuuming Emotions Stress Menstrual Cycle Odors Respiratory History: What respiratory problems have you been told you have by other physicians?

3 Please List Date Diagnosed with Illness Asthma Heart Failure Exercise Induced Asthma Pneumonia Bronchitis Pulmonary Fibrosis Bronchiectasis Tuberculosis COPD Sleep Apnea Emphysema Vocal Cord Dysfunction Interstitial Lung Disease Other

4 Initial Patient Medical History Name: ID Number: Review of Symptoms Please circle any of the following symptoms which you are currently experiencing or which have caused you serious problems in the past: General Fever, weight loss, weight gain, night sweats, severe itching, loss of appetite, fatigue, cold intolerance, heat intolerance Eye/Ear/Nose & Throat Loss of vision, blurry vision, cataracts, glaucoma, loss of hearing, itching in ear, ringing in the ears, loss of balance, loss of sense of smell, loss of sense of taste, excessive tearing, dry eyes, itchy eyes, conjunctivitis, ear infections, dry mouth, postnasal drainage Lymph Glands Glandular swelling, glandular tenderness Heart Chest pain, palpitations, swelling of ankles, inability to lie flat in bed Intestinal Tract Nausea, vomiting, heartburn, indigestion, trouble swallowing liquids or food, abdominal pain, constipation, diarrhea, excessive gas, food intolerances, gallstones, acid or sour taste in mouth, blood in stool Reproductive Irregular periods, skipped periods, unusual vaginal bleeding, menopause, infertility, miscarriages, impotence, unplanned pregnancy, planned pregnancy

5 Urinary Kidney stones, inability to urinate, prostate problems, kidney infections Rheumatologic & Orthopedic Early morning joint stiffness, joint swelling, joint pain, gout, low back pain, osteoporosis, fractured bones Skin Skin rash, hives, eczema, skin tumors or growths, excessive hair loss Neurologic Fainting spells, severe headaches, epilepsy (seizures), difficulty with memory, inability to concentrate Please elaborate on any symptoms which are particularly bothersome to you: General Office Forms\Initial Patient Medical History.wpd

6 Initial Patient Medical History Name: ID Number: Occupational or School History Are you currently employed? Y / N What is your current occupation? How long have you worked in this occupation? Do you believe that your current or previous occupation has any bearing on your illness? Y / N If yes, please explain: Are you unemployed (or on medical leave of absence) due to your medical illness? Y / N If yes, please explain: Do you have any pending or planned legal action against your current or former employer which pertains to your medical illness? Y / N

7 Have you ever worked in a factory, textile mill, grain mill, shipyard or mine, or on a farm? Y / N If yes, please explain: Have you had any job with high exposure to fumes, chemicals, dust, or other noxious substances? Y / N If yes, please explain: How much work or school have you missed due to your breathing difficulty within the past year? General Office Forms\Initial Patient Medical History.wpd

8

9

10 . Allergy & Asthma Center of NW Florida, P.A. Thomas G. Westbrook, M.D North Davis Highway, Suite 3 Telephone: (850) 473-ll2l Pensacola, Florida Fax: (850):!Z3 ll22 Consent to Treat Minor Child Without Guardian Present Patient Name: (Please Print) DOB: Parent Name: (Please Print) I give permission for my child to receive medical care, without parental presence, at the Allergy & Asthma Center of Northwest Florida, P.A. This care is to include: Office visits, skin testing, and knmunotherapy injections. It may also include any treatment deemed necessary for emergency care. I also give permission for the following people to accompany my child to the Allergy & Asthma Center of Northwest Florida, P.A. for treatment. Name: Relationship: In the event of an emergency, I can be reached at the following numbers: Home: Cell: Work: from to Pager: Emergency contact, in the event I carurot be reached at the above listed numbers. Contact Name: Relationship: Phone: Signature of Parent or Guardian Date \\Kristi\Dict\General Office Forms\Consent To Treat A Minor Chitd.*pd O:041503; R:030404

11 Allergy & Asthma Center of NW Florida, P.A. Thomas G. Westbrook, M.D North Davis Highway, Suite 3 Telephone: (850) 473-ll2l Pensacola, Florida Fax: (850\ 473-1,1,22. Pediatric Intake Name: DOB: Age: Place of Birth: City: State: Hospital: Pregnancy: Normal Y / N, Complications: Y / N: weeks Gestation: Delivery: CSection: Y/N, Reason: Vaginal: Y /N, Spontaneous / Induced Complications: Y / N, Jaundice / lnfection / Respiratory / Other: Mechanical Ventilation: Y /N, Birthweight: Newborn/Infancy: Growth & Development: Normal Y / N, Problems: Immunizations: Up to date: Y / N, Immunization Reactions: Y / N, Medications: Breast Fed: Y / N, How long? Reason for stopping: Formula: Enfamil / Isomil / Neutramagen / Other: Spitting up: Y / N, Stopped: Before 6 months I after 6 months Presently: Y / N Medications used for spitting up: Sleep: How much? Daycare: Y / N, At what age; _ Home: Relative: # of children per room: Hours / Days: Foods: Favorites: Snacks: Juices: Foodlntolerance /Allergies: Y/N, Peanuts ltreenuts / Egg/Milk/ Soy/ Shellfish/ Chicken Other: RashlEczema: Y / N, Onset: Birth i Age: Years Months Location on Body: " Infections: RSV: Y / N, Chicken Pox: Y / N, Pneumonia: Y / N, Ear: ( None / Occasional / Frequent ), PE Tubes: Y / N, Age:_,by Dr. Sinus: ( None / Occasional / Frequent ) Pharyngitis: Y / N, Strep: Y / N, Tonsiliectomy & Adenoidectomy: Y / N, by Dr. NasalComplaints:Chronic: Y/N, Snoring: Y/N, Apnea: Y/N, Hlperactivity: Y/N Chest Complziints: Chronic: Y/N, AsthmaDiagnosed: Y/N, When? \\Kristi\Dict\Cenelal Offi ce Forms\RN Forms\Pediatric Intake.wpd R:030304

12 Allergy & Asthma Center of Northwest Florida, P.A. Telephone: Thomas G. Westbrook, M.D. Fax: North Davis Highway, Suite 3 Pensacola, Florida It is now necessary to send your prescriptions electronically to your pharmacy. This is the information we need for our electronic medical chart. Thank you. Date: Patient Name: Date of Birth: Address (Street, City, State, Zip): Address: Phone # *************************************************************************** Insurance Information (please circle which insurance covers your medications) Primary: Policy #: Group #: Secondary: Policy #: Group #: *************************************************************************** LOCAL Pharmacy Name: Address: Phone #: Fax #: MAIL ORDER Pharmacy (ie. Medco/Tricare) : ID #: Phone #: Fax #:

13

14 ( )