Amy R. Ellingson, M.D. Laura Fouquette, PA-C
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1 Allergy & Asthma Specialty Clinic th Ave SW PO Box 1015 Willmar, MN Phone: Fax: Toll Free: ITCH (4824) Amy R. Ellingson, M.D. Laura Fouquette, PA-C Welcome to the Allergy & Asthma Specialty Clinic. We specialize in the care of adults and children with allergies, asthma, eczema, hives, anaphylaxis and immunodeficiency. During your initial visit, a detailed history and physical examination, pulmonary function test (if you have asthma) and allergy skin tests will be performed. For most allergy-related illnesses, every effort will be made to accomplish these tests in one visit. Please review the following information carefully. Appointment Scheduled For: Appointment Date/Time: Clinic Site: Willmar Office ( th Ave SW) Hutchinson Health Clinic (3 Century Ave SE) Marshall Avera Hospital Outreach Area (300 S. Bruce St.) IMPORTANT: YOU MUST STOP TAKING ALL ANTIHISTAMINE (anti-allergy) MEDICATIONS FOR 7 DAYS PRIOR TO YOUR APPOINTMENT. Taking an antihistamine would interfere with allergy skin testing. If you have any questions about your medication, please call our office and we will be happy to assist you. Some examples of common antihistamines are listed on page 2. **CHECKLIST** - BRING THE FOLLOWING TO YOUR APPOINTMENT: Patient History Questionnaire (enclosed). Complete the LEFT SIDE of the form only. Patient Registration Form (enclosed). Complete - do not leave any questions blank. Patient Insurance Card(s) including prescription plan card. Please verify coverage if you are in a special network or need pre-authorization prior to your appointment. It is your responsibility to obtain referrals, if needed. Patient Medical Records. A copy of your previous allergy/asthma related medical records, especially any allergy testing or lung function testing performed, is needed for review. Contact your previous clinic to obtain these or you can find a records release form on our website to submit by mail or fax. Medications. All prescription and over-the-counter medications you are currently taking must be listed in the Patient History Questionnaire. Please bring them with to your appointment. Method of Payment. Copays are due at time of services. A payment of $200 may be requested if you have an unmet deductible. Page 1 of 6
2 IMPORTANT: YOU MUST STOP TAKING ALL ANTIHISTAMINE (anti-allergy) MEDICATIONS FOR 7 DAYS PRIOR TO YOUR APPOINTMENT. This includes combination antihistamine/decongestants and over-the-counter allergy medications. Please be aware that antihistamines can usually be found in antidepressants, sleep aids and almost always in cough & cold medicines. Some common antihistamines include Allegra (fexofenadine), Atarax (hydroxyzine), Benadryl (diphenhydramine), Claritin (loratadine), Dimetapp, Tylenol PM, Xyzal (levocetirizine) and Zyrtec (cetirizine). You may continue taking nasal sprays (except Astelin, Patanase, and Dymista). If you are taking medications for anxiety, depression or trouble sleeping, please contact our office prior to stopping them. If you are taking asthma medications such as Advair, Symbicort, Dulera, Pulmicort, Asmanex, QVAR, Flovent, Ventolin, Xopenex, Proventil, albuterol, Maxair, Azmacort, Vanceril, Aerobid, Serevent, Accolate, Singulair or theophylline; it is important you continue taking them. Please bring all of your current medications with to your appointment. Call if you have questions. YOUR APPOINTMENT: Patients under 18 years of age must be accompanied by a parent or guardian. Initial appointments may take 1-2 hours so schedule appropriately and arrive 15 minutes early. As a courtesy to other patients and our office staff, please notify us at least 24 hours in advance if you must cancel or reschedule your appointment. If you fail to appear at your scheduled appointment without notification, we will not be able to schedule a future appointment. If you have questions or concerns, feel free to contact us toll free at or visit our website at FINANCIAL POLICY: Please understand that payment of your bill is considered a part of your treatment. We urge you to call us prior to your appointment to discuss the approximate cost of treatment. Please be prepared to pay the cost of your visit at the time of service (we accept checks, cash, and Visa and MasterCard). If you have current insurance please bring all insurance cards with you. We will file claims electronically to your insurance carrier; if any claim is disputed by the insurance company, the payment for that claim immediately becomes due. See our complete financial policy at the clinic. REFERRALS: If you are questioning whether your insurance requires a referral, please call the number on the back of your card. Most BlueCross BlueShield policies do not require a referral, except the policy with the state of Minnesota shown on the upper right corner (example shown below). LOCATION: Our Willmar clinic is located on the south side of 19 th Ave SW between Rice Home Medical and Evangelical Free Church. Turn south onto 11 th Street and make a quick left into our parking lot. Please call if you need help with directions. We thank you for allowing us to assist you. Please call us if you have any questions about your visit to our office. See you soon! Page 2 of 6
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4 Allergy & Asthma Specialty Clinic Amy R. Ellingson, M.D. PATIENT HISTORY QUESTIONNAIRE Patient Name: DOB: Date of Appt: Referring Physician: Patient accompanied by: Please complete the LEFT SIDE of this form (3 pages) Check box if you experience these symptoms: Sneezing, itchy/runny nose Nasal congestion, plugging, snoring, mouth breathing Postnasal drip, throat clearing Itchy, watery eyes Frequent yellow/green nasal drainage Loss of taste or smell Sore throat, voice changes, hoarseness Recurrent ear infections Recurrent sinus infections Frequent headaches Coughing, tickle coughs, spells of coughing Wheezing or shortness of breath Shortness of breath with exercise or coughing HPI: PHYSICIAN NOTES Diagnosis of asthma made years ago Number of past hospitalizations for asthma: Number of emergency room visits for asthma: Symptoms occur: Daily (circle one) More than 2 days per week Less than 2 days per week Symptoms occur at night: Every night (circle one) More than once a week 3-4 nights per month Use of albuterol: Last time prednisone was used? Days missed from school/work in past year? Possible reaction to food or drug Possible reaction to bee sting Eczema, dry/itchy skin Hives, swelling Other rashes Transfer of allergy care from Dr. Continuation of allergy shots started years ago These symptoms occur: (circle all that apply) Spring, summer, fall, winter Days or weeks at a time or all of the time. Triggered by exposure to: (circle all that apply) Smoke, dust, animals, mold, odors, perfumes, aerosols, mowing lawn, barns, raking leaves, cold air, temperature changes, dampness, menstrual cycle, emotional upset, viral infections, colds, or exercise. PRIOR ALLERGY WORK-UP: Sinus x-ray/ct Sinus surgery Skin tests Prior allergy shots - dates Helped / no help s Previous therapy tried: CXR Date Page 4 of 6
5 MEDICATIONS Please list all current medications including over-the-counter meds. List the drug name, dosage, how many times a day it is taken, and when it was started. PHYSICIAN NOTES If more room is needed, please attach a list. Bring meds with to your appointment. PAST MEDICAL HISTORY Birth complications? Breastfed? months. Bottle fed? months. Any history of RSV, infant eczema, or infant reflux/colic? Tuberculosis: exposure/infection/treatment Hospitalizations or surgeries: Age Reason Chronic health conditions: Drug allergies: Immunizations: (circle all that apply) Flu, pneumovax, prevnar, chickenpox, tetanus, other: FAMILY HISTORY Father: alive deceased at age allergies asthma sinus other diseases Mother: alive deceased at age allergies asthma sinus other diseases Brother(s): How many? Sister(s): How many? Children: How many? Medical problems: Medical problems: Medical problems: Other familial diseases (circle all that apply): High blood pressure, diabetes, heart disease, reflux, cancer, arthritis, emphysema, high cholesterol, thyroid disease, cystic fibrosis, other immune deficiency, or skin problems Page 5 of 6
6 SOCIAL HISTORY Primary residence: One home Split between homes: Current occupation: School/Daycare: Tobacco use: smoke cigarettes chew Amount per day: packs/tins Date began: Date quit: Total years of tobacco use: Secondhand smoke exposure from: Mom Dad Spouse Do you drink caffeine? No Yes, I drink cups/day of coffee/tea/pop Hobbies/sports include: PHYSICIAN NOTES CURRENT ENVIRONMENT/EXPOSURES House Farm Apartment Dorm Town Country Age of dwelling? How long have you lived there? Cigarette smoke exposure: None Indoors Outdoors Work Daycare Do you have any pets/animals? What type? Are your pets/animals indoors or outdoors? Air conditioning: Central Room None Open windows Heating system: Forced air Radiated Geothermal Other Gas Electric Fuel Oil Wood burning stove/fireplace Age of heating system: How often are the filters changed? Basement: Dry Musty/damp Visible mold growth No basement Do you use a dehumidifier? Bedroom location: Basement Main level Second floor Does the bedroom have carpet? If yes, how old is it? Type of bed (mattress, air, crib, etc.) and how old is it? Do you use dust mite zippered encasings: Pillows Mattress None Type of bedding (i.e. down comforter, feather pillow) Do you use any air cleaners? Do you use a clothes line? Any specific exposures at work or school? Latex exposure? Do your symptoms improve when away from home? REVIEW OF SYSTEMS (check if present) Growth and development problems Hearing/speech problems Fever, chills, night sweats, or significant weight loss/gain Sleep problems (snoring, apnea) Skin problems (besides eczema or hives) Joint swelling or pain Blood count problems (anemia) Eye problems (explain) Throat infections, hoarse voice, or trouble swallowing Heart problems (pain, racing heart) High blood pressure Upset stomach, nausea, vomiting, diarrhea or constipation Acid reflux, indigestion or ulcer disease Urinary or bladder problems Nerve or psychiatric problems Hormonal problems (hot flashes) Possible pregnancy or planned pregnancy Page 6 of 6
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
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
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:
Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
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New Patient Questionnaire
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Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:
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**No food or beverages are allowed in the exam room**
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Dear Patient, has an appointment
Muncie Allergy Center, P.S.C. Sai Karlapudi, M.D. & Jordan Overholt, F.N.P. 4505 North Wheeling Avenue Muncie, Indiana 47304 Phone (765) 284-4050 Fax (765) 284-9301 New Castle Clinic 1007 N 16 th Street
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Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
FOLSOM CARDIOLOGY. Registration Form. Office Use Only: Patient Acct #
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Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
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
MEDICAL HISTORY FORM
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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.
Parkinson Disease and Movement Disorder Institute
428 East 72 nd Street (Between 1st Avenue & York Avenue), Suite 400 (Ground Floor), NY, NY 10021 Telephone: 212-746-2584 Fax: 646-962-0517 156 William Street, 11 th Floor (Between Ann Street and Beekman
Welcome to the Rubin Institute for Advanced Orthopedics!
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MEDICAL DATA SHEET For Patients 18 years of age and older
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1620 South Queen Street, York, PA t: f: West Elm Avenue, Hanover, PA t: f:
Specializing in Allergy & Asthma Care for Over 30 Years Gregory B. Lanpher, M.D. Founder 1953 2009 1620 South Queen Street, York, PA 17403 t: 717.843.6663 f: 717.852.0670 420 West Elm Avenue, Hanover,
Office Policy for New Patients
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ENT & Allergy Specialists of VA Registration Form
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Thank you for choosing Therapy Works to assist you with your current condition.
Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
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Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
PATIENT INTAKE AND HISTORY FORM
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McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM
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3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
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
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
New Patient Information
New Patient Information Thank you for choosing Central Indiana Allergy. In order to provide the most thorough evaluation of your problems, we ask for your assistance with the following items: Complete