BOULDER MEDICAL CENTER, P.C.
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- Gervase Pearson
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1 BOULDER MEDICAL CENTER, P.C. Dear Patient, We are pleased that you have chosen our clinic for your medical needs. Here are a few suggestions to make your visit with us a pleasant experience. Please arrive 30 minutes prior to your scheduled appointment, this will give you ample time to check in at the front desk in our lobby and also, our department on the second floor. If you have arranged for outside records to be faxed or mailed to us we would suggest you call our office a few days prior to your appointment to make sure we have received them. If we have not received your records prior to your appointment, you may be asked to reschedule. Due to the length of an allergy consultation/work-up, there is a 48 hours cancellation policy. To avoid paying a no-show penalty please be sure to cancel your appointment 48 hours prior to your visit. To cancel your appointment please call (303) We look forward to meeting you. Thank you, Karen Andrews, MD Madeline Vogenthaler, NP 2750 Broadway 4745 Arapahoe, Suite Health Park Dr, Suite 100 Boulder, CO Boulder, CO Louisville, CO 80027
2 Patient Name History Number DOB BOULDER MEDICAL CENTER, P.C. KAREN ANDREWS, M.D. Please fill this form out BLACK INK ONLY MADELINE VOGENTHALER, NP prior to your appointment TEL: (303) FAX ADULT ALLERGY NEW PATIENT QUESTIONNAIRE PATIENT S PREFERRED NAME: PRIMARY CARE PROVIDER: REFERRING PROVIDER: VERY IMPORTANT: Please complete the following questionnaire as it is pertinent to the individual being evaluated. Completion of this form will assist us in evaluating and treating your allergy problem. Please bring the completed form with you to your appointment. Failure to do so may result in asking you to reschedule this appointment. Thank you. Briefly describe the main reason for your visit and what you hope to accomplish. A - 12 Have you ever had any of the following problems? Please check all items either Y, N or unsure Condition Y N Unsure Age at Onset Asthma (Wheezing) Other Breathing problems (cough, shortness of breath, frequent chest colds ) Sinus infections Nasal Polyps Hay fever (runny/stuffy/itchy nose) Hives or swelling Eczema Reactions to Foods (please list) Reactions to Drugs (please list) Reactions to Insect Stings Additional Comments: Comments Have you ever had any of the following symptoms? Symptoms Y/N How many days in the last month Runny or stuffy nose Itchy nose Sneezing Eyes: itching, watery Wheezing Coughing Wheezing or cough with exercise Night time awakenings due to shortness of breath or cough As sensation of choking or difficulty getting air in Skin problems Severity mild, moderate, severe Worst Season Spring, Summer, Fall, Winter Comments ALL.16 Rev 10/17 2 of 5
3 Patient Name Exacerbating Factors (Triggers) Please check each symptom box that that applies with exposure to the following: Animals (please name) Pollens/molds/mildews Respiratory infections, Colds Exercise Cold Air Foods Dust Air Pollution Fumes/Odors/Scents Car/Truck Exhaust Weather Changes Aspirin/Aspirin like drugs (ie ibuprofen, naproxen) Emotions/Stress Hormone changes/ menstruation Medications (please name) Work- related (please name) Symptom Asthma Nose/Sinus/Eyes Eczema Hives Comments Previous Allergy Evaluation and Therapy *Please bring copies of results if possible Allergy Skin Tests? Yes No Dates: Allergy RAST Testing? Yes No Dates: Allergy Injections? Yes No Dates: Start: End: Chest X-ray or CT scan? Yes No Dates: Sinus X-ray or CT scan? Yes No Dates: Have you ever needed sinus surgery? Yes No Dates: Medications: Please list any medications that you are currently taking for allergies (including inhalers, over the counter medications or herbal medicines) and any medications for other reasons. Current Allergy Medications Other Medications Name Dose Times per Day Name Dose Times per Day Please list any Allergy Medications you have tried in the past. Have you ever needed to take Oral Steroids for an allergic condition? (for example prednisone, dexamethasone) ALL.16 Rev 10/17 3 of 5
4 Patient Name Past Medical History: Please list any other illnesses or chronic medical conditions you have had. Please list any other illnesses or chronic medical conditions you have had: Please list all hospitalizations/surgeries: Please give reason and date Immunizations: Are they up to date? Have you received a Pneumovax? Do you receive a yearly influenza vaccine? Date: Family History Please list family members with any of the following: Asthma Hayfever Eczema Food Allergies Hives Cystic Fibrosis Recurrent infections Date: of last injection: Emphysema Autoimmune diseases Cancer Heart Disease Diabetes Glaucoma Other Social History: Marital Status: Single Married/Partner Divorced Separated Widowed Occupational History: (please list most recent job first) Job Title/Description Dates Please list any health risks/exposures Has your illness impacted your job performance? Do you have any hobbies that have potential exposures and/or affect your symptoms? Do you or have you ever smoked cigarettes? Number of years: Avg # of cigarettes/day: Age Quit: Current # of cigarettes/day: Other tobacco use? Type: Amount: Have you/do you have second hand smoke exposure? Do you have a history of any other type drug use (ie marijuana, cocaine)? Yes No If yes what type and was it inhaled or IV? Average amount of alcoholic beverages per week: Patient Name ALL.16 Rev 10/17 4 of 5
5 Environmental History Residence: Please list your current/past residences (city, state) with the current address first City/Town & State # of Years Effect on Symptoms/Exposures Please check all that apply regarding your current residence: Smokers in home? Wall-to-wall carpet? Pets/Birds in home? (what?) Do you vacuum? Swamp Cooler? Air purification system? Air conditioning? Pillow and mattress encasings? Humidifier? Leaking roof or basement? Heating? (type: forced air, electric, water) Mold or Mildew? Fireplace? (type: gas or wood burning) Located near a busy road? Wood burning stove? ALL.16 Rev 10/17 5 of 5
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.
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,
List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?
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?
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
Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F
Comprehensive Allergy and Asthma Care Center New Patient Questionnaire Patient Name: Age: DOB: Sex: M F Primary Physician (Name, Address and Phone Number): Do you want the allergy consultation note sent
Name: Date: How were you referred? Physician Other Self Referral. What problem brings you or your child to this appointment?
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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
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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:
NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician:
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Please Print When Filling Out This 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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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
ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:
ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE: A. Please check any of the following problems which you have had, and record when they started: Problem/Date of Onset sniffles nasal congestion
(pedi) Patient Name: date of birth:
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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:
PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.
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THE ALLERGY AND ASTHMA CLINIC
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ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR
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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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Patient Name: Date / Time of Appt: at
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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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Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)
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HEALTH QUESTIONNAIRE. Do not take antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hours
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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
Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs
HEALTH QUESTIONNAIRE Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs Patient s Name: Date of Birth: Date of Appointment: INSTRUCTIONS: Please
(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most?
6801 S. Yosemite St. Centennial, CO 80112 3260 E. 104th Ave. Thornton, CO 80233 18620 Green Valley Ranch Blvd. Suite 101 Denver, CO 80249 1551 Professional Ln. Longmont, CO 80501 Office: 303.773.9000 Fax:
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HealthyKidsExpress@bjc.org Asthma Words to Know Developed in partnership with Health Literacy Missouri Airways (Bronchi, Bronchial Tubes): The tubes in the lungs that let air in and out of the body. Airway
9834 Genesee, Suite 223B La Jolla, CA Phone Fax
PATIENT HEALTH QUESTIONNAIRE (Page 1) 9834 Genesee, Suite 223B La Jolla, CA 92037 Phone 858-277-7123 Fax 858-277-3470 ***Please fill out completely. Failure to do so may delay payment of your claim. Indicate
New Patient Information & Consents
New Patient Information & Consents Name: DOB: SSN: Gender: Address: City: State: Zip: Home #: Cell #: Other#: Employment Status: Occupation: Email Address: Marital Status: S M D W How did you hear about
Wisconsin Integrative Pain Specialists
Patient Information Today s Date: Patient s Name: DOB: Age: Gender: Marital Status: M S D What would you like us to call you? Address: City, State, Zip: Home Phone: Cell Phone: Work Phone: Email: Preferred
Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year
500 South University Suite 215 Little Rock, AR 72205 Phone 501-420-1085 Fax 501-420-1457 Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year How did you hear about our clinic? (Check
PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and REPORTS of any X- rays, MRI or Cat scans. Patient s name:
You Can Control Your Asthma
asthma_brochureprint_v2.qxd 9/5/06 9:54 AM Page 2 For More Information on Controlling Asthma: Centers for Disease Control and Prevention National Center for Environmental Health, MS F52 4770 Buford Highway,