Allergy & Asthma Affiliates 2121 Highland Avenue / Knoxville, TN Phone: (865) New Patient Questionnaire. Affix Patient Label Here
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1 Allergy & Asthma Affiliates 2121 Highland Avenue / Knoxville, TN Phone: New Patient Questionnaire Print clearly, and check 9 all that apply. Answer all questions from the patient s point of view. Mark N/A if not applicable. PATIENT S NAME First Name, Middle Name, Last Name HOME TELEPHONE GENDER PATIENT S ADDRESS Street, City, State, Zip / / WORK TELEPHONE PRIMARY CARE PHYSICIAN First Name, Last Name TODAY'S RACE DATE DATE OF BIRTH M F TELEPHONE PRIMARY CARE PHYSICIAN S ADDRESS Street. City, State, Zip WHO COMPLETED THIS QUESTIONNAIRE? if other than patient REFERRING PHYSICIAN First Name, Last Name TELEPHONE REFERRING PHYSICIAN S ADDRESS Street. City, State, Zip RELATIONSHIP TO PATIENT Staff Entering Data or Confirming Data in EHR: _ Signature: HAVE ANY OTHER FAMILY MEMBERS BEEN SEEN BY US? No Yes, if so, who? CHIEF COMPLAINT 1. Describe the reason for your visit and what problems or symptoms you are having. HISTORY OF PRESENT ILLNESS 2. Timing. When did the symptoms begin? Referral Source: PCP FOF YP OTH I was asked to see this patient in consultation 3. Quality. If pain, what does it feel like? No pain by: for: _ 4. Severity. How severe are the symptoms? Circle one VITALS: BP / P R mild very severe H W 5. Duration. How often do you have symptoms? 6. Context. Do symptoms occur at certain times or places? 7. Location. Where are the symptoms located? 8. Modifying Factors. Does anything make the symptoms worse? 9. Modifying Factors Cont.. Does anything make the symptoms better? 10. Assoc. Symptoms. Does anything else occur at the same time of your major problems? Page 1 of 6 Level 3 = 1 to 3 elements Level 5 = 4+ elements or 3 chronic / inactive HPI Level
2 REVIEW OF SYSTEMS 11. Are you bothered by any of the following symptoms in the following body systems? Mark 9 Yes or No for each. GENERAL Always tired. Chills / Fever.... Loss of appetite. Night sweats. Recurrent infections.. Trouble sleeping Weight gain / loss. E Darkness under eyes. Drainage Vision change... Eye pain Itchy eyes.. Light sensitivity Red eyes Watery eyes.. HENT Head Headaches. Sinus pain. Sinus infections. RESPIRATORY chart # _ DOB _ Chest tightness.. Cough wet.. Cough dry... Coughing up blood... Frequent colds or bronchitis. History of pneumonia... Shortness of breath... Wheezing.. GASTROINTESTINAL Abdominal bloating.. Abdominal pain Bloody stools Nausea or vomiting... Vomiting blood. Belching or excess gas.. Constipation.. Indigestion / heartburn.. Diarrhea GENITOURINARY Urinary frequency. Painful urination MUSCULOSKELETAL Ears Ear ache/pain Decreased hearing. Ear drainage.. Ear infections Ringing or popping ears... Nose Sneezing Runny nose... Loss of smell. Stuffy nose Itchy Nose Nosebleeds Excessive snoring. Throat / Mouth Sore throat. Hoarseness / laryngitis.. Difficulty swallowing... Loss of taste.. Itchy roof of mouth... CARDIOVASCULAR Shortness of breath w/exertion.. Bluish fingers or lips. Near fainting. High blood pressure.. Swelling of feet, ankles or hands. Cold hands or feet. Heart trouble. Joint swelling Stiffness Joint pain.. Muscle aches / cramps.. Redness. SKIN Seasonal allergies. Hay fever. Reaction to foods or drugs NEUROLOGIC Rash.. Birthmarks Hives / welts. Itching... Dry skin Change in skin color. Swelling Bruising Abrasions.. Skin infections.. ALLERGIC Headaches. Dizziness or poor balance. HEMATOLOGIC/LYMP. Swollen glands. Anemia / low blood.. ENDOCRINE All Systems Negative Except Noted Hair loss... List any other symptoms or concerns you have: Page 2 of 6 Level 3 = 1 Area Level 4 = 2-9 Areas Level 5 = 10+ Areas ROS Level
3 PAST MEDICAL HISTORY 12. MEDICATIONS. List any prescriptions, including bronchodilators, antibiotics, etc. and over-the-counter medicines, including vitamins, supplements and herbals you are currently taking or have taken within 60 chart # _ DOB _ days. a. Medication Strength How Often 13. OTHER ILLNESSES. List any illnesses or conditions you have ever had. a. Condition / Illness Age Currently Being Treated? Current Physician Yes Yes Yes Yes Yes No No No No No Current Status Resolved Active Stable Worse Resolved Active Stable Worse Resolved Active Stable Worse Resolved Active Stable Worse Resolved Active Stable Worse 14. FEMALES ONLY Not applicable a. Last Known menstrual period / / b. Chance of pregnancy? Yes No 15. IMMUNIZATIONS. a. Are your immunizations current? No Yes b. Do you receive annual flu vaccines? No Yes 16. REACTIONS. Please list any food, drug, or insect reactions or side effects you currently have or have had at some point in your life. None a. Cause Type of Reaction or Side Effect Rash/hives Swelling Itching Short of Breath Rash/hives Swelling Itching Short of Breath Rash/hives Swelling Itching Short of Breath Rash/hives Swelling Itching Short of Breath b. Have you ever had allergy skin testing? No Yes c. Have you ever been on allergy injections? No Yes 17. SURGERIES / INJURIES. List any surgeries or injuries since birth. a. Surgery or Injury Performed by Complications? Outcome Where Age or Yr b. Any previous injury to nose? No Yes 18. HOSPITAL / ER VISITS. List any hospital or ER visits within the last 5 yr a. Reason Length of Stay Complications Hospital Age or Yr 19. PAST TRANSFUSIONS a. Have you ever had blood or blood product transfusions? No Yes Page 3 of 6
4 PEDIATRIC PAST MEDICAL HISTORY ** Complete #20 - # 23 only if patient is a minor ** 20. PREGNANCY & BIRTH a. Is your child yours by: Birth Adoption Stepchild Foster b. Birth weight: Type of Delivery: Vaginal Caesarian c. Age of mother at time of delivery d. Full term or Premature How many wks premature? e. Any delayed separation of umbilical cord > 1 month? No Yes f. Prolonged jaundice over 2 weeks? No Yes g. Intestinal obstructions during infancy? No Yes h. Any other newborn problems? No Yes chart # _ DOB _ 21. NUTRITION & FEEDING a. Was your child breastfed? No Yes If so, how long? b. Was you child bottle-fed? No Yes If so, how long? c. Were formula changes required? No Yes d. Has your child had any feeding/dietary problems? No Yes 22. DEVELOPMENT a. Has you child had any of the following delays? Circle if so. Walking Learning Talking b. Any difficulties with growth or weight gain? No Yes 23. SCHOOL HISTORY a. Did/does your child attend preschool? No Yes b. How many days of missed school in the last year due to illness? c. Is your child in daycare? No Yes How many days per week? At what age did they start daycare? _ d. What grade is your child in? Circle one N/A P K e. School performance: Above average Average Below average FAMILY HISTORY 24. Place a check mark under the appropriate family member if they have experienced any of the following conditions or diseases. Write in any conditions or diseases not listed. Condition Allergies / hay fever Asthma / RAD Bronchitis Lung disease Sinusitis Cystic Fibrosis Immune deficiency Migraine headaches Recurrent Infections Stomach Conditions Food allergies Skin disease Lupus Rheumatoid Arthritis Mom Mom s Mom s Dad s Dad s Mom Dad. Dad Mom Dad Sis. Bro. Other Page 4 of 6
5 SOCIAL HISTORY 25. TOBACCO USE / EXPOSURE a. None Current Use chart # _ DOB _ Prior Use Year Started _ Year Quit Type: Cigarettes Cigars Pipe Smokeless How many times/packs per day? b. How often are you exposed to second-hand smoke? Sometimes in public/work Often in public / work Sometimes at home Often at home None more than 3 c. How many smokers in home? 26. FAMILY SITUATION a. Marital Status: Single b. If a minor, are child s parents: Married Married Separated Divorced Unmarried Separated Divorced Widowed c. Who lives at home with you? Name Age Elem. Jr. High High School College Elem. Jr. High High School College Elem. Jr. High High School College Elem. Jr. High High School College Elem. Jr. High High School College Elem. Jr. High High School College Relationship Occupation Highest Education Level d. In the past year, have there been family changes? Check all that apply Marriage Separation Divorce Loss of Job Move New School Birth Serious illness Death Other 27. ACTIVITY/EXERCISE LEVEL Answer only one a. Inactive no regular physical activity Ex. sit-down job Light activity no organized physical activity during leisure time. Moderate activity occasionally involved in activities Ex. jogging Heavy activity Exercise or active sports at least three times per week b. Type of activityies: c. Any limitation of athletic or work activities? No Yes 28. DIET a. The majority of my meals are Fast-food Home-cooked Restaurant b. Do you follow a special diet? No Yes If so, please describe: c. Caffeine drinks: Coffee Tea Soft Drinks How many per day? 29. DEMOGRAPHICS a. Child / Student Employed Retired Unemployed Disabled Employer / School: Birthplace: b. Number of missed school or workdays because of illness? _ c. Any occupational exposures to chemicals, fumes, etc? No Yes d. Education: K 12 Some College Degree Obtained Page 5 of 6
6 ENVIRONMENTAL HISTORY PATIENT S RESIDENCE 30. What is the age of your home? chart # _ DOB _ 0 10 years years years > 20 years 31. How long have you lived at current residence? 1 year or less 1 5 years 32. What type of home do you live in? Frame house Brick house Apartment 33. Where is your home located? City 34. Does your home have a basement? No Yes Suburb 6-10 years Country / Rural over 10 years Mobile Home Other Farm Near water Other If Yes Ö Water leaks Damp Previous problems with leaks 35. What type of heating? Central or Space: gas electric oil wood kerosene 36. What type of air conditioning? Central 37. How often are air filters changed? N/A Weekly 38. What other air devices do you use? Fans Dehumidifiers 39. Is there any noticeable mold or mildew? No Yes If Yes, where? Bathrooms Basement Bedrooms Kitchen 40. Is there any fume exposure? No Yes If Yes, what type? Cleaning supplies Aerosols Fragrances Window None Monthly Less often Humidifiers Air filter/cleaner Paint / Varnish 41. Do you spend time at other residences? No Yes 42. Is there any animal exposure? No Yes If Yes, indicate the number of each animal. If other, write in what type and how any. Animal Exposure Location Dog Cat Bird Rodent Horse Farm Animals Other At home, indoors At home, outdoors Other School / Sitter 43. Do you have any indoor plants or flowers? No Yes If so, how many? over Have there been any pest problems? No Yes If so, what? Roaches Other insects Mice Other: 45. Where does the problem seem to be worse? Bedroom Living room Kitchen Basement Garage Indoors Outdoors PATIENT S BEDROOM 46. Indicate the items found in patient s bedroom. Mattress pad Stuffed furniture Heavy drapes Venetian blinds Carpeting 47. How many beds in bedroom? or more 48. How many persons in bedroom? or more 49. What type of mattress? Spring Foam Bunk Water Crib Other 50. What type of pillow? Cotton Feather Foam Polyester Other 51. Are vinyl covers used? No On mattress On pillows 52. What type of flooring? Carpet Hardwood Tile Linoleum Bookcase Quilts/Comforters Stuffed toys Plants Thank you for taking the time to complete this questionnaire! Please bring this with you for your appointment. PLAN: PROVIDER Level 4 SIGNATURE 1 element PMFSH Billing Level 5 2+ elements Level OVER HALF OF THE TIME SPENT WITH THE PATIENT WAS SPENT IN FACE TO FACE COUNCILING. Page 6 of 6
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