ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR
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1 ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR Name D.O.B. Date Reason for your visit today: Please put a check and complete the blanks which apply to your symptoms: Present Problem Past Problem Not a Problem Eye symptoms: (wear contacts? ) Y/N c c c Watering c c c Redness c c c Swelling c c c Burning c c c Dryness c c c Foreign Body Sensation c c c Symptoms in the upper respiratory tract (nose, sinuses, throat, Eustachian tubes, voice box): Sneezing c c c Congestion c c c Headache c c c Obstruction c c c Drainage c c c Soreness c c c Dryness c c c Hoarseness c c c Hearing Loss c c c Polyps c c c Snoring c c c Impaired Smell/Taste c c c Symptoms in the lower respiratory tract (windpipe, bronchi, lungs) Coughing c c c Wheezing c c c Tightness-Congestion c c c Shortness of Breath c c c Sputum production c c c
2 Symptoms in the stomach and digestive system which you suspect might be allergic: Present Problem Past Problem Not a Problem Pain/difficulty swallowing c c c Nausea or vomiting c c c Heartburn/indigestion c c c Abdominal cramping c c c Constipation/Diarrhea c c c Hives/Giant Swelling? c c c Eczema? c c c Skin reaction to poison ivy/oak, metals, chemicals or cosmetics? c c c Reaction to food (s) c c c List foods Reaction to bee, hornet, wasp, yellow jacket or other stinging insect bite c c c Reaction to immunization c c c Latex reactions (gloves, balloons, etc) c c c Problems with Immune System c c c Frequent/serious infections c c c Review of Systems (Please indicate if you are currently experiencing any of the following): General: Cardiovascular: c Fatigue c Chest pain c Anemia c Palpitation c Fainting c Edema (swelling) of the legs c Night sweats c Night coughs c Low-grade fever c Irregular heartbeats c Dizziness c Other: c Other: HEENT: G.I.: c Frequent colds c Heartburn c Hoarseness c Nausea c Tonsillitis c Vomiting c Swollen glands c Abdominal pain c Blurred vision c Diarrhea c Ear infection c Nosebleeds c Other:
3 Respiratory: Musculoskeletal: c Shortness of breath c Arthritis c Difficulty breathing c Joint swelling c Chest tightness c Back pain c Coughing c Stiffness c Wheezing c Coughing blood c Other: Skin: c Easy bruising c Hives c Skin infections c Eczema c Other: Medication Allergies & Intolerances: c NO KNOWN MEDICATION ALLERGIES OR INTOLERANCES PLEASE LIST ANY MEDICATION ALLERGIES OR INTOLERANCES: MEDICATION NAME DATE OF REACTION TYPE OF REACTION (Attach extra information if more than 5 medication reactions) FAMILY A/I HISTORY Father Mother Sibling Paternal Maternal Grandmother Grandmot /father her/father Asthma c c c c c c None Rhinitis/Hayfever c c c c c c Dermatitis (Eczema) c c c c c c Autoimmune disease c c c c c c
4 Environmental History: Residence Location: Suburban Urban Rural Type of Residence: House Apartment Other Basement: No: Yes( Damp Dry) Air Conditioner: Central Window/Wall Units None Dehumidifier Humidifier Heating System: Forced Air Radiator/Basebord Space heater Fireplace/Wood Stove/Furnace filter changed every months Type of Floors: Living area Carpet Wood Vinyl Other ( ) Bedroom: Carpet Wood Vinyl Other ( ) Type of Bed: Waterbed Conventional Mattres Boxspring ( Allergy encasement) Type of Pillow: Feather Polyester/Dacron Foam ( Allergy encasement) Pets: NO PETS Dog: Outdoor Indoor Bedroom Cat: Bird: Outdoor Indoor Bedroom Outdoor Indoor Bedroom Other: Outdoor Indoor Bedroom *Smokers in Residence: None Yes ( ) Occupational History: Current Occupation Any current exposure to occupational antigens/irritants (dust, mold, pets, grass, pollen, paint, fumes, chemicals, VOCs, pollutants, smoke)? Yes No (If yes, details ). Any previous exposure to occupational antigens/irritants? Yes No (If yes, details Immunization Status (Vaccines): Date of Last Influenza (Flu) Vaccine? (if known) Date of Last Pneumovax or Prevnar (Pneumococcal pneumonia) vaccine? (if known) Signature: Date:
5
New Patient Questionnaire
- - Toda y 's Date: Primary Care Provider's Name: Was a consultation recommended? Primary Clinic: Referring provider's name (if different): Please answer the following questions to facilitate the diagnosis
9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY
Name: Date of Birth: Date of Visit: Briefly describe the reason for your visit: How long have you had these problems? How frequently do you have them? NASAL SYMPTOMS ALLERGY HISTORY 1. I have the following
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
Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
180 Montgomery Street, Suite 2370 San Francisco, CA 94104 Tel: (415) 433-6673 Fax: (415) 433.6063 www.mydrd.com Jeffrey M. Davidson, M.D. Certified by the Board of Allergy and Immunology Clinical Professor,
Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:
Dr. Bina Joseph Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician: Describe each problem that has led you to seek this allergy evaluation: 1. 2. 3. 4. Drug Allergies:
ALLERGY & ASTHMA SPECIALISTS, P.C.
ALLERGY & ASTHMA SPECIALISTS, P.C. Leonard Silverstein, M.D. Ruth L.K. Gold, M.D. Health Questionnaire Jennifer A. Sherman, D.O. Niya Wanich, M.D Patient: D.O.B.: / / Age: Date: / / Height: Weight: Reason
Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present
BRIEFLY DESCRIBE THE REASON FOR THIS VISIT (what is your main concern or symptom?): CHECK SYMPTOMS YOU HAVE OR HAVE HAD: Nasal Symptoms Past Present Nasal congestion Runny nose Nasal discharge Postnasal
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
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
Telephone Number Home: Work: Cell:
Page 1 of 7 Patient Name: DOB: Date: Address: Occupation: Telephone Number Home: Work: Cell: Emergency Contact: Relation: Telephone: Address: Referring Physician: Address: Telephone: ***ALL PATIENTS MUST
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
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.
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
PULMONARY MEDICINE PATIENT QUESTIONNAIRE
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PATIENT INFORMATION. Last Name First Name Address Zip Code City State
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Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint:
Julie A. Wendt, MD, PLLC 21803 N. Scottsdale Rd, Ste 200 Scottsdale, AZ 85255 (480) 500-1902 PATIENT HEALTH QUESTIONNAIRE Today s date: Referring Doctor: Patient s last name: First: Middle: Birth date:
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:
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
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Medical History Form
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
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
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Name: Date: 1. What is the principal reason for consulting us?
Name: Date: 1. What is the principal reason for consulting us? 2. Circle any of the following that you have had: Sneezing Runny nose Stuffy nose Shortness of breath Phlegm Headaches Watery eyes Swelling
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Richmond Office 4718 National Rd. E. Richmond, IN
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PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
NAME: AGE: ---- Date of Appointment:. ID (For Office Use Only): RETURN VISIT Date of Visit: Main Reason for visit: Reevaluation Family Doctor: Symptoms worse _ New problem _ Yearly follow up _ Follow up/office
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NEW PATIENT INTAKE FORM
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child s last name: first name middle iditial: date of birth / /
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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
MEDICAL HISTORY FORM
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ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #200 MAPLE GROVE, MN TEL (763) FAX (763)
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Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs
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List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
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1 New Patient Registration Please Print New Patient Name (Last, First, Middle ) Nickname Maiden / Former Name Male / Female Single / Married / Divorced / Widowed Age Date of Birth Social Security Number
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NEW PATIENT QUESTIONNAIRE
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725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
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PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
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Patient History Form
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APPLICATION FORM & QUESTIONNAIRE GENERAL INFORMATION (Please print) Today's date Name Age Sex (M,F) Place of birth Birth date Marital status Number of children Living situation (alone, family, friends)
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
PATIENT INFORMATION SHEET
ALAMO NEUROSURGICAL INSTITUTE 414 W SUNSET, SUITE 205 SAN ANTONIO, TEXAS 78209 WWW.ANI-ONLINE.COM OFF: 210.564.8300 FAX: 210.564.8399 PATIENT INFORMATION SHEET Patient Name (Last, First, Mi): SSN: Street
SOC SEC #: - - Date of Birth: - - Age: yrs. State: Zip Code: Employer:
PATIENT INFORMATION (PLEASE PRINT) SOC SEC #: - - MRN#: Home Phone: Work Phone: Ext: Address: City: Cell Phone: Date of Birth: - - Age: yrs State: Zip Code: Employer: SEX: Male Female Work Address: City:
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
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
Review of Systems NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient,
LOS ANGELES CANCER NETWORK NEW PATIENT HEALTH QUESTIONNAIRE NAME: DATE OF BIRTH: DATE COMPLETED: Dear Patient, In order to offer optimal care for you, we need to understand your complete health status