PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY
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- Anissa Randall
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1 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 to advance your care. Name of Birth Home phone # Work phone # Occupation (current and previous) Referring or primary physician name Present Illness: What is the main reason for today s consultation? Hayfever, sinus problems, frequent head colds? No Yes Asthma, bronchitis, frequent chest colds? No Yes Hives? No Yes Eczema? No Yes Skin rash from cosmetics, detergents, metals? No Yes Insect allergy No Yes Food allergy No Yes Drugs or other allergies? If yes, please specify. No Yes Recurrent infections No Yes Others, please specify: No Yes (Please do not write in this space) 1
2 Have you ever been allergy tested? No Yes If yes, when and where? Did you ever receive allergy injections/de-sensitization? No Yes If yes, when and for how long? Have you received allergy/asthma treatments or medications? No Yes If yes, please list: Have they helped? No Yes Approximately how much time loss (days) from work or school due to your allergy problems have you had this past year? I am bothered by (check all that applies) Eyes Itching Redness Watery Discharge Burning Swelling Blurry vision Light sensitive Ears Itching Fullness Popping Pain Loss of hearing Vertigo/ Dizziness Nose Itching Sneezing Congestion Runny Post nasal drip Mouth breathing Sinus Congestion Pain Colored Facial Headache Toothache drainage fullness Chest Congestion Tightness Shortness of breath Wheezing Cough Colored sputum Nighttime awakening Exercise symptoms Skin Itching Redness Scaling Cracking Hives/welts Pain My symptoms are worse during (check all that applies): Seasons Temperature Time Places/Activities Winter Cold Daytime Indoor Spring Heat Nighttime Outdoor Summer Weekdays Work/School Fall Weekends Home My symptoms are bothered or affected by (check all that applies): Upper respiratory infections Dusting or vacuuming Cut grass Exercise Cats Damp (musty) basements Perfume/Cosmetics/Soap Dogs Hay or Barns Aerosols/ Smoke Other animals: Dusty basements/attics Paint/Chemical irritants Dusty books/magazines Foods Others, please specify: (Please do not write in this space) 2
3 Environmental Survey: 1. Do you live in a home/ apartment? (please circle) 2. How old is your home/ apartment? 3. How long have you lived there? Is there a basement? No Yes Is there carpeting? No Yes Is the carpeting on cement slabs? No Yes 6. Do you have down(feather): pillows? No Yes down(feather): comforters? No Yes 7. What type of heating system do you have? (please circle) Wood burning stove/ Forced air/ Radiator (electric, gas, or steam)/ Coal/ Humidifier/ Other 8. Do you have pets? (please circle all that applies) No Yes Cats/ Dogs/ Birds/ Others 9. Do you have houseplants? No Yes 10. Is there water damage or mold in your If yes, please describe: home or workplace? No Yes 11. Do you smoke (cigarettes, pipe, cigar) or If yes, for how many years have/did you smoked? have you smoked in the past? No Yes 12. Are you exposed to smokers? No Yes 13. Do you or have you ever used illicit drugs? No Yes 1 Do you drink alcohol? No Yes How many drinks per day? per week? 1 Where have you lived (cities, states)? 16. What are your hobbies? Please list your medical problems: Please list your surgical & hospitalization histories: Medications: Please list all your medications, including over-the-counter medications and herbal supplements: -Please don t forget to list the strengths and how often you take them-- Have you had allergic or adverse reactions to any medications or immunizations? No Yes If yes, please list the medication(s) or immunization(s) and the associated reactions: 3
4 Immunizations: Are your immunizations up to date? No Yes Did you receive the influenza (flu) immunization last fall/winter? No Yes Have you ever received the pneumonia vaccine (Pneumovax)? No Yes Have you had the following studies? Studies: When? Result? Pulmonary function test/spirometry No Yes Chest X-ray or CT-scan No Yes Sinus X-ray or CT-scan No Yes Blood work No Yes PPD/TB Skin Test No Yes EKG, Stress Test, Echocardiogram No Yes Others No Yes Please list your family medical (especially allergy) histories: We are especially interested in any history of asthma, lung diseases, hay fever, cough, any nasal or sinus problems, breathing issues, food allergy, eczema, hives, recurrent swellings, migraines, repeated infections, insect allergy, sudden death, and other major medical problems (e.g., thyroid, diabetes, lupus, cancer, and etc.). If living, Age of If deceased, Medical problems (Don forget to list any Relation Age health death cause? breathing (nose/chest)) or skin issues. Father Mother Brother(s) or 1. Sister(s) Son(s) or 1. Daughter(s) Paternal 1. Grandparents 2. Maternal 1. Grandparents 2. Aunt(s), 1. Uncle(s) or 2. Cousin(s)
5 NEW PATIENT REVIEW OF SYSTEMS Name: DOB: Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems may affect your overall course of care. PLEASE MARK ALL SYMPTOMS THAT HAVE BEEN AN ISSUE IN THE PAST (P) AND/OR ARE CURRENT (C) ISSUES CONSTITUTIONAL: P C P C P C CARDIOVASCULAR: ENDOCRINE: Fatigue / tiredness / weakness High blood pressure Abnormal thirst or hunger Headache Heart attack, Coronary Artery disease Diabetes or elevated blood sugar Sleeping difficulty Chest pains Thyroid problems Drenching night sweats Heart palpitations or fluttering WOMEN ONLY Shaking chills Swelling of the feet or legs Irregular menses, periods, pelvic pain Weight gain or loss >15 lbs Heart murmur Are you currently pregnant? Snoring Need to sleep on > 1 pillow Fatigue upon awakening Lightheadedness or fainting spells GENITOURINARY: Need to nap during the day Need to sleep with head above heart Getting up during the night to urinate Difficulty with concentration / memory Rheumatic fever or heart disease Urinating more than every 2 hrs Fevers Difficulty urinating GASTROINTESTINAL: Urinary or bladder disease DERMATOLOGIC: Heart burn / abdominal pain Kidney stones / kidney disease Rashes Constipation Swelling Diarrhea / Colitis MUSCULOSKELETAL: Itching without rash Hemorrhoids Arthritis or Rheumatism Frequent skin infections or boils Rectal bleeding or blood in stool Bursitis, muscle or joint pain Stomach or Duodenal Ulcer Back pain EYES, EARS, NOSE, THROAT: Jaundice/Liver disease Glaucoma Gallbladder disease NEUROLOGIC: Cataracts Stroke Blurred Vision INFECTION: Seizures, convulsion, epilepsy, Eye disease, injury or impaired sight Measles paralysis Corrective glasses / contact lenses German Measles (rubella) Loss of Sensation Hearing Loss Mumps Dizziness, fainting episodes Ear disease, injury or impaired hearing Chicken pox Neuritis or neuralgia Nosebleeds Whooping cough Ringing in the ears / Tinnitus Chronic sore throat or hoarseness Scarlet fever Sleep Apnea Meningitis HEMATOLOGIC: Tuberculosis Anemia/bleeding tendency RESPIRATORY: Histoplasmosis or Coccidiomycosis Easy bruising Shortness of breath Hepatitis Frequent cough Gonorrhea, Syphilis, Chlamydia, PSYCHIATRIC: Coughing up blood Genital Herpes Suicidal thoughts Pneumonia Exposure to AIDS Severe depression Pleurisy Overwhelming anxiety Other Everything that is not marked will be noted as not being an issue 5
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MEDICAL DATA SHEET For Patients 18 years of age and older NAME: DATE: / / AGE: DOB: / / 1. What is the main reason you are seeking a physician s advice? 2. Please list all allergies: Drug Allergies: Other
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL
REDROCK MEDICAL GROUP INITIAL HISTORY AND PHYSICAL NAME: BIRTH DATE: AGE: SEX: M F OCCUPATION: RACE: WHO REFERRED YOU TO OUR OFFICE? _ WHAT IS YOUR MAIN COMPLAINT? HOW LONG HAS THIS BEEN A PROBLEM? IS
Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY
PATIENT QUESTIONNAIRE / ASSESSMENT Endocrinology Form Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY Date Phone (H) (W) (C) Age Male Female Marital
John Wayne Cancer Institute Dr. Foshag Dr. Faries Dr. Bilchik Dr. Leuchter
John Wayne Cancer Institute Dr. Foshag Essner Dr. Fischer Dr. Faries Dr. Foshag Dr. Bilchik Dr. O'Day Dr. Leuchter Medical Questionnaire Reset Form Date: Name: Gender: Male Female Age: Last First Middle
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
child s last name: first name middle iditial: date of birth / /
P E D I AT R I C PAT I E N T 1 child s last name: first name middle iditial: date of birth / / please answer all questions to the best of your knowledge. completion of this intake information is an essential
Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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
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
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
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
New Patient Questionnaire Pediatric Orthopaedic Surgery
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SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
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