Adult Allergy & Medical History
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- Homer Morgan
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1 Adult Allergy & Medical History Ridhu C. Burton, M.D. How did you hear about our office? Referral by another physician Referral by another patient Phonebook listing Internet Ad; Please circle one Google, Bing or Yahoo Other: Name: Birth Reason you were sent to an Allergist: Prior allergy tests (date & where): Prior allergy injections (date & where): Prior Chest x-ray/ct (date & where): Do you now or have you had any problems related to the following? Circle Yes or No. Diabetes Y N Hypertension (high or low blood pressure) Y N Cancer Y N Stroke Y N Convulsions Y N Heart Disease Y N Asthma Y N Arthritis/Gout/Rheumatism Y N Lung disease Y N Blood Disease Y N Kidney Disease/Stones Y N Peptic Ulcer/ GERD Y N Constitutional symptoms Gastrointestinal Fever Y N Heart burn/indigestion Y N Night sweats Y N Abdominal pain Y N Weight change Y N Nausea/vomiting Y N Eyes Diarrhea/constipation Y N Cataracts Y N Cancer/Tumor Glaucoma Y N Location Contact Lenses Y N Urologic Neurologic Prostate enlargement Y N Migraines Y N Urinary infections Y N Cardiovascular Respiratory Irregular heart beat Y N Croup Y N Chest Pain/Angina Y N Obstructive sleep apnea Y N Pacemaker Y N Skin Palpitations Y N Eczema Y N Endocrine Hives Y N Thyroid disease Y N Psoriasis Y N Osteoporosis Y N Immunologic Elevated cholesterol Y N Recurrent infections Y N
2 Psychological HIV Y N Blood transfusion Y N Depression Y N Immunizations Complete Y N Anxiety Y N Past Surgeries and dates, if known: 1. Year 4. Year 2. Year 5. Year 3. Year 6. Year I. Living Environment-Circle the following A. Type of structure: Home Apartment Mobile Home Location of Home: Urban Rural Suburban Proximal to: Factories Granaries Farm Approximate age of home: How long have you lived there? Any smokers in residence? Yes No B. Do you have the following: Basement Crawl Space Slab Type of basement: Block Poured Finished Michigan cellar Basement in winter: Dry Damp Basement in summer: Dry Damp Basement musty or moldy: Yes No Basement leaks with rain: Yes No Dehumidifier in basement: Yes No Symptoms worse in basement: Yes No Ridhu C. Burton, M.D. C. Type of Furnace: Gas Wood Oil Electric Coal Location of furnace: Basement Crawl space 1 st floor Heating system: Forced air Radiator Steam Fireplace Space heater Type of Filters: Disposable Permanent Electrostatic How often is filter changed: Central air conditioning: Yes No Room air cleaner: Yes No Humidifier on furnace: Yes No Portable humidifier location Fireplace or wood burning stove: Yes No D. Patient s Bedroom location: Basement 1 st floor Upper floor Bedroom Floor coverings: Carpet (shag) Carpet (short pile) Wood Tile Vinyl Living Area Floor coverings: Carpet (shag) Carpet (short pile) Wood Tile Vinyl Bed coverings: Feather comforter Yes No Pillow(s): Polyester Foam Feather Cotton Pillow age Are pillows encased? Yes No Mattress: Cotton innerspring Foam Water Feather Mattress age Is Mattress encased? Yes No Is Box Spring encased? Yes No Pets in bedroom: Yes No E. Is there mold growing anywhere in the house: F. Is there anything in your building, yard, or around your house that has not been mentioned that you think is significant in contributing to your problems?
3 II. Inhalant History A. Dust: Dust exposure may cause either Nasal or Lung symptoms or both. With the following dust exposures, indicate which symptoms are worse by circling N to indicate Nasal, L to indicate Lung, O to indicate None, and U to indicate Unknown. Dusty garage: N L O U Breathing house dust: N L O U Outdoor dust: N L O U Dusting and/or vacuuming: N L O U Feathers N L O U B. Molds/Pollens: Do your symptoms worsen after exposure to the following: Hay: Yes No Unknown Raking Leaves: Yes No Unknown Barns: Yes No Unknown Cut grass(dried/fresh): Yes No Unknown Damp Basements: Yes No Unknown Eating mushrooms: Yes No Unknown Eating cheese: Yes No Unknown C. Danders: Please indicate the number of pets you own, their age and circle whether they are indoor or outdoor? Cat # Age Outdoor/Indoor/Bedroom Dog # Age Outdoor/Indoor/Bedroom Parakeet # Age Outdoor/Indoor/Bedroom Other # Age Outdoor/Indoor/Bedroom What animals aggravate your symptoms? Are you exposed to animals in your workplace? Yes No If so, what animals? D. Miscellaneous: Which, if any of the following produce onset or an increase in symptoms? Aerosols (sprays) Nose Chest Both Newspaper print Nose Chest Both Perfumes Nose Chest Both Tobacco smoke Nose Chest Both Strong chemical odors Nose Chest Both Detergent powders Nose Chest Both Diesel/gasoline fumes Nose Chest Both E. Physical Agents: Do you have onset or increase of symptoms after exposure to the following? Temperature change Yes No Onset Increase Exercise Yes No Onset Increase Drafts Yes No Onset Increase Sunlight Yes No Onset Increase Weather changes Yes No Onset Increase Dampness/rain Yes No Onset Increase Wine/beer Yes No Onset Increase Barometric pressure change Yes No Onset Increase
4 III. Do foods cause any symptoms? A. Name Food and Associated Symptoms IV. Social History A. Please indicate amount of use where applicable Alcohol Coffee/caffeine Recreational drugs Hobbies (hives, rash, runny nose, nausea, vomiting, diarrhea, headache) Smoking Current Past Never Total number of years of smoking If you were a smoker, date quit Average packs per day (cigarette, cigar, pipe) V. Drugs A. Have you ever had an adverse or allergic reaction to any medication? Drug Reaction Date VI. Insect Stings: A. Have you ever had an unusual reaction from an insect sting? Yes No Type of insect Type of reaction: VII. Prescription Pharmacy (please choose a pharmacy if you do NOT currently have one) 1. Local Pharmacy: Address: Phone #: Mail Order Pharmacy:
5 VIII. Medications A. List all current medications including strength and how often you take it: Med Name: Strength (i.e. mg): Frequency: IX. Have you had the Influenza Vaccine? What was the date of your last Influenza Vaccine? No Yes Please list any other vaccines you have had: (pneumonia, shingles etc.)
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.
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
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
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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
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SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:
Name: Date of Birth: What is the reason for your visit today? What doctor referred you to this office? PAST MEDICAL HISTORY: Do you have any of the following: Please check all that apply Anxiety /depression
NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name
NEW PATIENT FORM Please print in ink and fill in all blanks Please fill out front and back Patient s Full Name Date of Birth Age Sex Social Security Number Referring Doctor or Family Physician Phone #
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
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
![Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?](/thumbs/87/97078208.jpg "Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?")
ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
Air pollution and health
Air pollution and health Dr. Amir Elahi Johri, MBBS, MPH, ACIEH, FRSPH Consultant Air Pollution It is the introduction of chemicals, particulate matter or biological materials that cause harm or discomfort
Adult Health History
Patient Name Date of Birth Adult Health History This form will assist us in obtaining a complete medical history and health record on you. By completing this ahead of time it will also simply your visit
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth: