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1 Muncie Allergy Center, P.S.C. Sai Karlapudi, M.D. & Jordan Overholt, F.N.P North Wheeling Avenue Muncie, Indiana Phone (765) Fax (765) New Castle Clinic 1007 N 16 th Street Dear Patient, has an appointment Thank you for choosing Muncie Allergy Center for your care. Please call us to confirm your appointment at when you receive this packet. Our office requires a 24-hour cancellation and in the event that we do not receive this notice, there will be a $25.00 fee. Please fill out the patient history form and bring this packet along with any insurance cards to the office the day of your appointment and be prepared to pay any co-pay required by your insurance. Please bring a list of all medications that you are currently taking and records of previous treatments including written x-ray reports, lab, skin tests, or blood test results. Many times if you call your family doctor and ask, s/he will send a letter describing your treatment along with pertinent medical records. Your primary care physician s office can provide a Release of Information form which can be sent to other physicians or hospitals prior to your appointment. If you will be seeing us in regard to nasal allergies, sinus trouble, and/or asthma, we may need to do allergy skin testing, which means you should not take antihistamines for 5 days prior to the scheduled appointment. Many over the counter medications that say allergy contain antihistamines. If in doubt ask your pharmacist. Antihistamines that will need to be stopped 5 days prior to your appointment are Allegra (fexodendaine), Allegra D, Claritin (loratadine), Claritin D, Clarinex, Clarinex D, Zyrtec, Zyrtec D,.Xyzal pills & Astelin, Astepro, Patanase nasal Sprays. If you are taking blood pressure medicine, call before your appointment to speak with a nurse. Most other medications, including asthma medications, will not interfere with skin testing and should be continued. If you have a skin rash or hives, it is not necessary to stop your medication for the first visit.. Please call us at with any questions. Our office is located 8/10ths of a mile North of McGalliard Road on the West side of Wheeling Avenue and 2/10ths of a mile South of Riggin Road. You are scheduled for a 2-hour appointment. Please plan on being here the full time if necessary. If the patient is a young child, it is helpful to bring along favorite toys or even a second adult to keep the child occupied for this length of time. Thank you for your cooperation as we are making every effort to see you in a timely manner. Please visit our website listed above for directions to our Muncie and New Castle locations. Sincerely, Sincerely, Sai Karlapudi, M.D. Jordan Overholt, F.N.P. 1
2 Please answer the following questions about yourself or your child: What is the main reason you are here today? How long have symptoms been present? The following list includes s list of symptoms. For the symptoms indicate whether they are (1)mild, (2)moderate, or (3) severe 1, 2, 3 CHEST SYMPTOMS 1, 2, 3 THROAT OR SINUSES sore throat shortness of breath tonsillitis tightness in chest bad colds wheezing hoarse/laryngitis coughing sinus infections wheezing or coughing worse with exercise? postnasal drainage wheezing or coughing worse at night? headaches (see below) have you ever had bronchitis, pneumonia, or croup? sinus surgery more than once? nasal polyps how many times have you been hospitalized for asthma? last hospitalization? last emergency room visit? 1, 2, 3 NASAL SYMPTOMS stuffiness/congestion itching of nose or mouth frequent sneezing clear thin drainage throat clearing loss of smell or taste snoring/noisy sleep nose bleeds 1, 2, 3 SKIN rashes eczema hives poison ivy 1, 2, 3 EYES watering or tearing itching or redness light hurts eyes dark circles under eyes puffy around eyes dry or gritty eyes thick discharge eye pain 1, 2, 3 EARS frequent infections stopped up trouble hearing itching dizziness pain ringing ear surgery (tubes) 2
3 HEADACHES How frequent are the headaches? Any other family members with headaches? Are there certain times of the year or types of weather when your symptoms are worse? When? What other activities or exposures (hobbies, work, strong odors, etc.) can you think of that make your symptoms worse? _ Have your symptoms been helped by any medications you have tried in the past? _ About how many days of work or school per year do you miss from the above symptoms? Have you had an adverse reaction to an insect sting and were you prescribed medications for it? Please list below. Have you had any allergic reactions or any type of bad reactions to medications? If so, describe. Are these any foods which cause you to have rashes, cramps, swelling, or asthma? If so, describe. _ Do you now, or did you ever smoke? If yes, what and how much per day? Have you stopped smoking? _ How many years have you smoked? Are you exposed to tobacco smoke at home or at work? 3
4 Please list all present medications. Please include dosage, strength, and number of times a day taken. Please also include over-the-counter medications including aspirin or other pain medications, laxatives, or vitamins. How many times have you taken antibiotics in the past year? _ Can you recall the names of any of the antibiotics? Have you ever received cortisone or steroids in injection or tablet form? If so, how frequently? Please list all previous surgical procedures, serious accidents, or injuries with approximate dates. Please list any other hospitalizations (including childbirth) and the medical diagnosis and treatments with approximate dates. Are you under a doctor s care for any other medical conditions? (blood pressure, diabetes, etc.) REVIEW OF SYSTEMS: Do you now have or have you had difficulties with any of the following? _Diabetes or thyroid trouble _Glaucoma or other eye problems _Stroke, weakness, convulsions _Emphysema _Swelling of feet or ankles (edema) _Stomach or digestive problems _Arthritis _Bladder or kidneys _Prostate _Female problems _Cancer _Unexpected weight loss or gain 4
5 IF YOU HAVE ANY BLOOD RELATIVES WITH THE FOLLOWING PROBLEMS. PLEASE CHECK THE APPROPRIATE COLUMN. Asthma Hayfever Eczema Hives Sinus Problems Mother Father Brother Sister Children Aunt Uncle Grandfather Grandmother Do any blood relatives have: Diabetes Heart disease Frequent infections Emphysema High blood pressure Cancer PREVIOUS ALLERGY EVALUATIONS Have you ever had an allergy evaluation in the past? If yes, at what age was the allergy evaluation done?. Circle the diagnosis that was made: Hayfever Asthma Eczema Sinus Other If you were skin tested, to what were you found to be allergic? Trees Grass Weeds Molds Dust Animals Feather Foods Other Have you received allergy injections in the past? What improvements have you noticed? _ COMPLETE THE FOLLOWING QUESTIONS FOR CHILDREN UNDER EIGHT Any breathing problems or other complications in the nursery? Please explain Breast fed? How long? Bottle fed? Type of formula? Any difficulties with formula? DURING THE FIRST YEAR OF LIFE DID THE CHILD HAVE: Skin rash (other than diaper rash) More than one ear infection Nasal congestion (severe) Chest cold Wheezing Colic more than 3 months Unexplained diarrhea 5
6 ENVIRONMENTAL HISTORY Please circle appropriate answers or fill in the blanks. Neighborhood: urban suburban rural cultivated fields woods near water House Apartment Mobile Home Time living there approximate age of dwelling Basement: damp dry ever flooded finished Crawl Space: damp dry ever flooded Heat: forced air gas electric oil gas stove radiant heat ceiling cable baseboard radiator wood heat kerosene fireplace used frequently used infrequently Air Conditioning: none central window used frequently used infrequently Humidifier Dehumidifier Fan Use of: potpourri air freshener other aerosols Pets: Dog # inside outside in bedroom Cat # inside outside in bedroom Others: Including exposure to farm animals Bedroom: # of beds regular mattress plastic dust-proof mattress cover water bed stuffed animals in room on bed pillows feather foam rubber polyester all bedding (blankets, spreads, etc.) washable? old quilts down comforter clutter old books upholstered furniture carpeting Employment History: Present type of employment Exposure to smoke, fumes, or other hazards Daycare History (for children): Age when daycare started number of other children at facility. 6
7 PLEASE DO NOT WRITE ON THIS PAGE Date _ PHYSICAL EXAMINATION NAME _ Ht Wt BP PEFR Eyes: Conjunctivae OK injected cobblestones lids puffy dark circles Ears: Rt TM OK injected dull scarred amber fluid Lt TM OK injected dull scarred amber fluid Nose: No abnormality septum deviated straight no mucus scant clear white yellow thick bloody polyps Rt Lt excoriations membranes normal pink red pale lavender edema none slight Throat: tonsils absent or small enlarged inflamed posterior pharynx normal inflamed lymphoid hypertrophy postnasal drainage none clear thin yellow/green thick Cervical glands: unremarkable shotty small nontender enlarged tender Thyroid: unremarkable palpable Chest: Abdomen: Musculoskeletal: Skin: 7
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Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
Alka-Seltzer Plus Multi-Symptom Cold Day & Night Effervescent Tablets
Do not take these products at the same time. Alka-Seltzer Plus Multi-Symptom Cold Day Effervescent Tablets Drug Facts Active ingredients (in each tablet) Purposes Aspirin 325 mg (NSAID)*...Pain reliever/fever
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
NEW PATIENT HISTORY AND PHYSICAL FORM
Temp: BP: Ht: P: WT: R: NEW PATIENT HISTORY AND PHYSICAL FORM Patient s Name: Age: Sex: Male Female CHIEF COMPLAINT: (why you are here today) History of Present Illness LOCATION of pain / problem? HOW
IT IS YOUR RESPONSIBILITY TO CHECK WITH YOUR INSURANCE CARRIER TO MAKE SURE YOUR VISIT WILL BE COVERED
Appointment Date: Appointment Time: Patient: Welcome to The Pain Management Center with services provided by American Health Network. Please keep this information and let it serve as a reminder for your
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Jagdeep Hundal, MD, Otolaryngology, Head & Neck Surgery 774 Christiana Rd, Suite B4, Newark, DE Phone: Fax:
Allergy Questionnaire Patient Name Date / / 1. What symptoms do you suffer from? Please circle below Eyes: Itchy eyes, tearing, eye redness, eye discharge Ears: Popping sensation, fullness, itching Nose/Sinus:
Symptom Review (page 1) Name Date
v2.4, 2/13 JonathanTreasure.com Botanical Medicine & Cancer Herb Drug Interactions Herbalism 3.0 Symptom Review (page 1) Name Date INSTRUCTIONS Please read each section below carefully and, after each
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY
PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY New Patient Questionnaire. Please answer all the questions as completely as possible. We appreciate your effort in helping us obtain current and complete information
Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Johanna M. Hoeller, DC PS
ENTRANCE FORM Birth date: Height: Weight: Emergency Contact: Emergency Contact Phone: ( ) Spouse/Partner or Parent s name: Children s names: Occupation (Your): Employer: Address: City/State/Zip: Phone:
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s