1 Dear Patients, Welcome to Mercy Clinic Asthma, Allergy and Immunology. *We are looking forward to seeing you for evaluation of your allergy symptoms. In order to make the best use of your appointment time, please note the following. *Please contact your insurance provider to check your benefits and see if a referral is required. Benefits can vary from one insurance to another and even one plan to another within the same insurance. Skin Testing *Many new patients are skin tested. Obtaining accurate results requires discontinuing certain medications prior to your appointment. Please see the Preparation for Allergy Evaluation on page 1. *If you are unsure you will need skin testing please contact our office. Urticaria (Hives) *If you are being evaluated for urticaria (hives), you will not be skin tested on the first visit. Please continue all medications. Asthma Medications *If you are taking asthma medications continue taking those medications until your appointment but do not take any of the medications listed on the Preparation for Allergy Evaluation on page 1. *Please bring any inhalers, spacers or peak flow meters you may have. *Filling out the enclosed Mercy Clinic Registration Form, Allergy History Form and Consent and Agreement form will help your time in our office be more efficient. *Your initial visit may take approximately two hours depending on the testing needed. Please arrive 15 minutes prior your appointment. Please bring insurance cards, photo ID, co-pay and a list of your medications. To cancel or reschedule please call two business days prior to your scheduled appointment. If you cancel with less than a 24 hour notice you may be subject to a $25.00 cancelation fee and your appointment will be considered a no show. Patients that do not arrive for their appointments may also be subject to a $25 no show fee.
2 *If patient is younger than 18 years of age, patient must be accompanied by parent or legal guardian. Crestwood Location: 10024 Watson Road, St. Louis, MO 63126 Mercy Medical Group (between Johnny Macs Sporting Goods and Commerce Bank) From South County: From St. Louis City: Take I-270 North, exit I-44 East I-44 West to Lindbergh Blvd, turn left Take MO-360 E. Watson Road (exit 5A) Take ramp to Watson Road and turn left Turn slight right onto Watson Road East 1.25 Location on the right Location on the right
3 Clayton-Clarkson Location: 15945 Clayton Rd. Ballwin MO 63011 Suite 220 **PLEASE NOTE** Dr. Temprano sees patients at this location on Wednesdays ONLY!
4 PREPARATION FOR ALLERGY EVALUATION In order to obtain accurate test results, you must be off antihistamine medications prior to your visit. Below is a list of some common allergy medications and the length of time they must be stopped before skin testing. This is not a comprehensive list: if you are unsure if your medication contains an antihistamine please ask your pharmacist or call our office. Medications: discontinue 6 WEEKS prior to skin testing Astemizole Medications: discontinue 2 WEEKS prior to skin testing Allegra Extendryl Allegra D Fexofenadine Atarax (hydroxyzine) Hydroxyzine Cetirizine Xyzal (Levocetirizine) Clarinex (Desloratadine) Zyrtec Medications: discontinue 1 WEEK prior to skin testing Alavert Loratadine Claritin Walitin Claritin D Examples of other medications: discontinue 3 DAYS prior to skin testing Actifed Alka-Selzer Plus Allerest Benadryl Bromfed Bromophen TD Brompheniramine Cheracol Plus
5 Chlorphiniramine Chlor-Trimeton (CTM) Clemastine Contac Coricidin Tablets Co-Tylenol Cyproheptadine Dexchlorpheniramine Dimetane Dimetapp Diphenhydramine Drixoral Dristan Naldecon Novahistine (Cold & Hay Fever) Nytol 4 way Cold Tablets Pediacare 2 & 3 Periactin Poly-Histine Percogesic Promethaxine Sinarest Sinutab Sine-off Sominex Sudafed Plus Triaminicol Triminic (not DM or expectorant) Trinalin Tyipelenamine Tri-Phen-Chlon Tylenol PM Rynatan Robitussin Night Relief Vicks Nyquil **Most OTC (Brand Name and Generic) cold and cough medicines, sleep aids, and anti-nausea medicines contain an antihistamine; please read the active ingredients label and stop 3 days before skin testing.*** Nasal sprays: Astelin---discontinue 2 weeks prior to skin testing Astepro--- discontinue 2 weeks prior to skin testing Azelastine---discontinue 2 weeks prior to skin testing Olopatadine--- discontinue 2 weeks prior to skin testing Patanase--- discontinue 2 weeks prior to skin testing ***All other nasal sprays may be continued, they will not interfere with testing.***
6 MERCY CLINIC REGISTRATION FORM Date of Appointment: PATIENT DEMOGRAPHICS Name: SS# SEX: Male Female Birth date: Aliases: How were you referred to us: Who is your Primary Care Physician: Permanent Address Address: Home Phone: Work Phone: City: Mobile Phone: State: Zip: E-Mail: Language: Interpreter needed: Yes No Marital Status: Preferred Pharmacy for Patient Pharmacy name: Pharmacy address, if known Phone: Fax: PATIENT EMPLOYMENT Employer: Employment Status: Address: City:
7 State: Zip: Phone: Country: Fax: EMERGENCY CONTACT INFORMATION Contact 1 Name: Home Phone: Address: Work Phone: Mobile Phone: City: Relationship to Patient: State: Zip: Legal Guardian: Yes No County: Contact 2 Name: Home Phone: Address: Work Phone: Mobile Phone: City: Relationship to Patient: State: Zip: Legal Guardian: Yes No County: Who is financially responsible for this patient s account? Self Employer Spouse Father Mother Other Responsible Party Information: Name: Date of Birth: SS# Address: Primary Insurance Coverage: INSURANCE COVERAGE INFORMATION Who is the subscriber for the coverage? Address: Date of Birth: SS# Employer: Insurance Coverage Name:
8 Group# Subscriber#: Member ID#: Secondary Insurance Coverage Who is the subscriber for the coverage? Address: Date of Birth: SS# Employer: Insurance Coverage Name: Group# Subscriber#: Member ID#:
9 Laura Esswein, M.D. Asthma, Allergy and Immunology Mercy Clinic, Crestwood 10024 Watson Road Saint Louis, Missouri 63126 James Temprano, M.D. Asthma, Allergy and Immunology Mercy Clinic, Crestwood 10024 Watson Road Saint Louis, Missouri 63126 Mercy Clinic, Clayton-Clarkson 15945 Clayton Road, Suite 220 Ballwin, Missouri 63011 Allergy History Form Name: Date of Birth: Primary Physician: Whom may we thank for referring you today? BRIEFLY DESCRIBE THE SYMPTOMS THAT LED TO THIS VISIT: Check each item with date of onset: Hay fever (itching of nose, sneezing, stuffy nose, runny nose), onset: Asthma (wheezing, cough, shortness of breath, chest tightness), onset: Other breathing problems, shortness of breath, onset: Hives or swelling (urticaria/angioedema), onset: Sinus trouble (infections, decreased sense of smell and taste), onset: Eczema or other rashes, onset: Food allergies (hives, anaphylaxis, shock), onset:, dates of occurrence: Frequent or recurrent infections, onset: Drug allergy, please list medications and briefly describe symptoms and dates of occurrence: Bee sting or insect hypersensitivity (large swelling, hives, shock, or other): dates of occurrence: Eosinophilic esophagitis or eosinophilia, onset: dates of last endoscopy, results:
10 Symptoms: Have you had any of the following symptoms? Sneezing: mild/moderate/severe Nasal congestion: mild/moderate/severe Runny nose: mild/moderate/severe Itchy eyes: mild/moderate/severe Coughing: mild/moderate/severe If you are COUGHING, please characterize it further Cough upon getting up or first thing in the morning Sudden episodes of cough occurring infrequently Chronic hacking cough Frequent episodes of cough associated with phlegm production Cough on most days for 3 consecutive months or more each year Coughing up blood For how long have you been bothered by cough? Wheezing: mild/moderate/severe Coughing or wheezing with exercise: mild/moderate/severe Headaches: mild/moderate/severe If you have NIGHTTIME SYMPTOMS, please describe respiratory symptoms you have at night: Coughing which interrupts sleep Significant phlegm production during the night Wheezing or a feeling of chest tightness Inability to sleep lying down flat due to cough or shortness of breath Awaken very congested and/ or short of breath in the morning Geographic History :( please circle one) Mowing lawn, walking on grass or playing in grass: High winds, or riding in auto with windows open, air conditioning: Sweeping, dusting, using vacuum cleaner: Moldy or mildewed areas or articles / Exposure to mold or mildew: Strong odors: example: household cleaners, paints, perfumes
11 Trips away from home (specify area and time of year): Smoking or smoke exposure: Emotional upsets: Heavy or physical exertion or exercise: Environmental History: Which of the following best describes your living situation (private home, apartment, mobile home, etc.)? Where is the home located (rural, city, near any major factories, industries, etc)? Age of home How long have you lived there? How many people in home? Home description: Basement? Any water damage in basement? If yes, please explain: Any dampness in the home, water leaks, mold or mildew problems? If yes, please explain: Does anyone in the home currently smoke? Relationship to Patient: Indoors? Smokes, but outside of the home? Air conditioning? Central or room? Forced air heating? Gas or electric? Wood burning stove? Used how often? Any unvented stoves in the home? Mice or cockroaches in the home? Mold or mildew in the home? Wall-to-wall carpeting in any room? How old? Is there carpeting in the patient s bedroom? Feather pillows? Down comforters? Air purification systems? Pillow and mattress dust-proof encasings? Pets? What kind and how many? Do any pets sleep in the same room as the patient? Plants in the home? How many? In what room are the plants located?
12 Occupational History: Are you currently employed? Do you attend school? What is your current occupation? How many hours per week do you work? Do you believe that your current or previous occupation has had any bearing on your illness? If yes explain: Days missed of school or work in past 6 months? Describe, if any, the effect of your illness on your job or school performance: Smoking History: Have you ever smoked? Are you still smoking? How old were you when you started? How old were you when you quit smoking? How many packs a day did you or do you average? Prior Allergy History: Have you ever noticed any symptoms (hives, swelling, asthma, stomach ache, vomiting or diarrhea) after any of the following foods? Milk Eggs Wheat Fish Shellfish Peanuts Other nuts Other foods: Explain: Have you ever had allergy skin test? If yes, approximate year(s) Doctors name/ location: Do you recall the results of the test? If yes, please list positive tests: Did you ever receive allergy injections? If yes, approximate years: Were they helpful? Are you up to date on your immunizations? Not Sure Can you tolerate NSAIDs (IE aspirin, Advil, ibuprofen, Aleve)? Yes No If no, why? Medications: Please list your current medications (please include inhaled medications, including a nebulizer): Name Strength Number of Times Taken Per Day Daily use or only as needed 1. 2. 3. 4. 5. 6. What other medications have you taken in the past for asthma or allergies (including nose sprays)?
13 Medication Allergies: Please list the names of any medications to which you have experienced an allergic reaction Name of medication Describe allergic reaction Past Medical History: (check all that apply) High blood pressure Seizures Glaucoma High cholesterol COPD Lupus Diabetes Kidney disease Nasal Polyps Cystic fibrosis Liver disease HIV/AIDS Rheumatoid arthritis History of tuberculosis Stroke Thyroid disorder Inflammatory bowel disease: Crohn s or Ulcerative colitis
14 Have you ever been hospitalized for any illness? If so, when and for what reason? Date of admission Length of hospitalization Diagnosis or reason for hospitalization Please list any other conditions for which you are receiving current medications or treatment: Previous Tests: List any previous testing you have undergone, give approximate dates and results Approximate date Result Bronchoscopy Pulmonary function testing and/ or Methacholine challenge Rhinoscopy Operation on nose or sinuses CAT scan of sinus CAT scan chest Tonsils or adenoids removed Ear tubes placed, how many? Sweat chloride test ph probe Immunoglobulin/ Immune system studies Family History: If yes, who is affected? Rel. to Pt Asthma Cancer Emphysema Tuberculosis Nasal Allergies Immune Deficiency Stroke Cystic Fibrosis Diabetes Sinus Surgery Eczema Nasal polyps Rheumatoid arthritis Lupus Thyroid disorder HIV/AIDS Inflammatory bowel disease: (Crohn's or Ulcerative colitis) Rel. to Pt Last updated 12/2/16
15 Review of Systems: Circle any of the symptoms you are currently experiencing, or which have caused serious problems in the past Constitutional: Fever, weight loss, weight gain, night sweats, severe itching, loss of appetite, fatigue, cold intolerance, heat intolerance Special senses: Loss of vision, blurry vision, cataracts, glaucoma, loss of hearing, itching in ears, ringing ears, loss of balance, loss of sense of smell, loss of taste, excessive tearing, dry eyes, itchy eyes, conjunctivitis, ear infections Lymph gland: Heart: GI: Reproductive: Gland swelling in neck, under arms or groin area, gland tenderness Chest pain, palpitations, swelling of ankles, inability to lie flat in bed Nausea, vomiting, diarrhea, heartburn, indigestion, trouble swallowing Liquids or solids, abdominal pain, constipation, excessive gas, food Intolerances (lactose intolerance), gallstones, acid or sour taste in mouth Irregular periods, skipped periods, unusual vaginal bleeding, menopause, Infertility, miscarriages, impotence Are you pregnant now or planning a future pregnancy? Rheumatologic: Early morning joint stiffness, joint swelling, joint pain, gout, low back pain, Osteoporosis, fractured bones Skin: Neurologic: Rash, hives, eczema, skin tumors or growths, excessive hair loss Passing out, severe headaches, seizures, memory difficulty, inability to Concentrate Last updated 12/2/16