Mr. Ms. Mrs. Dr. First MI Last. Zip City State. Zip City State. Zip City State. Zip City State. Mr. Ms. Mrs. Dr. DOB: First MI Last.
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4 Date / / History No.: Patient Information Street Mr. Ms. Mrs. Dr. First MI Last Mailing Phone Date of Birth SS# Occupation Gender M F Marital Status Employer Employer Phone Family Doctor Referring Doctor RESPONSIBLE PARTY Street Mr. Ms. Mrs. Dr. DOB: First MI Last Mailing Phone Home Work SS# Employer Employer Phone Relationship to Patient 4 of 14 PATIENT REGISTRATION FORM (Please Turn Over)
5 Insurance Information PRIMARY Insurer Mailing Insured s Name First MI Last DOB Policy No. Group No. Plan Insurance Information SECONDARY Insurer Mailing Insured s Name First MI Last DOB Policy No. Group No. Plan EMERGENCY NOTIFICATION NEXT-OF-KIN (not living with patient) Name Phone Home Work PARENTS OF MINOR PATIENTS NOT LISTED AS RESPONSIBLE PARTY Name Mother Father Phone Home Work How did you hear about us? Friend Family Internet Advertisement Physician Other AUTHORIZATION TO RELEASE INFORMATION TO INSURANCE COMPANY I authorize the release of any medical information necessary to process my insurance claim. Signed: Responsible Party Date 5 of 14
6 PRE-VISIT QUESTIONNAIRE In an attempt to serve you in a timely fashion, we are furnishing you with this questionnaire with the request that you complete this information prior to your scheduled visit. We look forward to seeing you. Your Name: Date of Birth: Date of Visit: Acct.# (to be filled-in by staff) Current Medications and/or Supplements (e.g., vitamins) (Please list all medicines you are currently taking for any reason) Name of Medicine Dose How often are you taking? Name of Medicine Dose How often are you taking? Please document any medicines to which you are allergic and the type of reaction (e.g., rash) Other Medical Conditions: Past Allergy History: 1. Have you seen an allergist in the past for your symptoms? Yes No a. If yes: Doctor's Name: When? b. Did you have skin testing? Yes No c. Prior diagnosis: Allergic Rhinitis Asthma Hayfever Hives Eczema Urticaria Insect sting If you have been treated in the past it would be helpful if you could bring your previous records to your visit. d. Prior treatment: None Prescription meds Allergy shots Over-the-counter meds Avoidance measures General Childhood History: 1. Were there any complications at birth? No Yes If "yes" please describe. 2. Childhood illnesses: Routine illnesses Recurrent ear infections Recurrent sore throat Recurrent sinus infections Skin Rashes Respiratory difficulty Mumps Measles Chickenpox Allergies Asthma 3. Immunizations: N/A Current Not Current Family History: Please indicate if your family member has had any of the following: Disease Asthma Cystic Fibrosis Hay fever Eczema Heart disease Thyroid disease Arthritis/Lupus Bronchitis Food Allergies Migraine Headaches Diabetes Cancer Father Father s Mother Father Mother Mother s Mother Father Sister Brother Daughter Son 6 of 14 Page 1 of 2 - (Please turn over)
7 PRE-VISIT QUESTIONNAIRE (continued) Social History: q Child 1. Marital Status: Married Single Divorced Separated Widowed N/A 2. Number of children: 3. Do you smoke? Yes No If yes: less than 1 pk/wk less than 1 pk/day 1-2 pks/day more than 2 pks/day 4. How long have you smoked? Less than 5 yrs years years more than 20 years 5. Have you stopped? Yes No If yes: this year 1-3 years ago more than 3 years ago 6. Are you exposed to secondary smoke? Yes No If yes: Home Work 7. Do you chew tobacco or dip snuff? Yes No 8. Alcohol(wine/beer): No Daily Occasionally Weekly 9. Days absent from school/work due to illness? 0 less than Are there any unusual exposures on the job? Yes No If yes, please describe (e.g. toxins, mold) 10. Occupation: Environmental History: Please check the appropriate boxes. (In some cases you may need to check more than one box) 1. Home Location: Inner City Urban(City) Suburbs Rural (Country) Age of home: 2. Home Type: Apartment Condo House Mobile Home 3. Air Conditioning: None Central Window Ceiling fans Window fans 4. Heat: Baseboard Forced Air Electric Gas Heat pump Oil Radiant Radiator Space Heater Wood Stove 5. Filters: None Electrostatic Fiberglass Hypoallergenic 6. Mold: None Baseboards Basement Bathroom Crawl Spaces Windows 7. Bedroom Floor: Area rug Cement Full carpet Pile: Low Med High with pad no pad Hardwood Linoleum Tile 8. Bedroom Windows: Bare Curtains: washable non washable Miniblinds Roll-up blinds Shades Plantation/Wooden blinds 9. Mattress: Old New Crib Foam Inner spring Waterbed Encased Not Encased 10. Pillows: Dacron Feather Foam None Encased Not Encased 11. Objects in bedroom: Cluttered Somewhat cluttered Uncluttered 12. Pets: Cats Dogs Indoor/ Outdoor Other animals: Bird Hamster Horse Gerbil Rabbit Farm Animals Indoor/ Outdoor 13. Hobbies/Sports: None Indoor Outdoor 7 of 14 Page 2 of 2
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Please Print When Filling Out This Form
Please Print When Filling Out This Form For Office Use Only Patient #: Location: Date of First Appointment: Patient Information Patient s Name: Home: ( ) Address: _ Street City State Zip E- Mail Address:
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Dr. Vivek U. Rao, M.D. 500 Adams Ave., Suite 300 Odessa, TX 79761 Phone: 432.333.3300 Fax: 432.339.3300 Medical History Form Patient Name: DOB: A. CHIEF COMPLAINT: Briefly describe your (or your child
Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
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Allergy/Immunology Questionnaire
Anita Shvarts, M.D. 85 Seasons Lane Hiawassee, GA 30546 [p] 855.656.6673 [f] 877.811.4836 Allergy/Immunology Questionnaire Please take a moment to complete this form. It will help the practitioner better
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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.
Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE
Page 1 of 5 Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE NAME: AGE: DATE OF BIRTH: Primary/Referring Physician: Phone #: Other Subspecialists
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Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)
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
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
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
Richmond Office 4718 National Rd. E. Richmond, IN
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NEW PATIENT HISTORY Patient s Name: Last First Middle Age: Primary Care or Referring Physician: Name Address Please check Yes or No: Symptoms Eye Symptoms Cough? Itching? Wheeze? Watering? Tight Chest?
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First Middle Last Mailing Address: Primary Phone: Street City Zip Secondary Phone: Date of Birth: Male Female SSN: Emergency Contact Phone: Marital Status: Single Race: American Indian or Alaska Native
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
NORTHERN ARIZONA ALLERGY, ASTHMA, & IMMUNOLOGY
NORTHERN ARIZONA ALLERGY, ASTHMA, & IMMUNOLOGY 930 N. Switzer Canyon Drive, Suite 101 Flagstaff, Arizona 86001 Phone: (928)-774-1700 Fax: (928)-226-8634 PATIENT HISTORY FORM PATIENT NAME: GENDER: FEMALE
An affiliate of Saint Mary's Health System FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM. Last Name: First Name: DOB: Age:
FRANKLIN MEDICAL GROUP, PC. NEW PATIENT INTAKE FORM Last Name: First Name: DOB: Age: Date of Service: Present Occupation: Marital Status: Married Divorced Single Widowed Partnered List household Members
Race (Check one): White Black Asian American Indian/Eskimo/ALEU Hawaiian Native/Pacific Islander Other
Please mail or fax to: Dallas Transplant Institute Pre-Transplant Group 1420 Viceroy Drive Dallas, TX 75235 Fax: (214) 366-6088 Donor Name: SS#: Date of birth: Age: Sex: Male Female Address: City/State/Zip
NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Last Name: First Name: Date Form Completed: Referring Physician: Address: City: Sex: Marital Status: Race: Age: Married Caucasian Single Male Divorced African American Hispanic
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,
Room # Critical Care & Pulmonary Consultants, P.C.
Room # Critical Care & Pulmonary Consultants, P.C. Health History You have been scheduled for an appointment with Critical Care and Pulmonary Consultants, P.C. This health history will help us facilitate