Asthma & Allergy Clinic REGISTRATION FORM

Asthma & Allergy Clinic REGISTRATION FORM 1 Today s date: Primary Care Provider: Referred by: PATIENT INFORMATION Patient s last name: First name: Middle: Marital status: married divorced widowed separated single Date of birth: Age Sex: M F Address: City: State: Zip code: Social Security #: Home phone: Cell phone: Work phone: Employer: Email address: Preferred Pharmacy with phone # Spouse s name: Spouse s SS #: Spouse s cell phone: RESPONSIBLE PARTY AND INSURANCE INFORMATION (PLEASE PROVIDE YOUR INSURANCE CARD TO THE RECEPTIONIST) Person responsible for the bill: Relationship to the patient: Address, if different: Telephone number: Please indicate primary insurance: Subscriber: Subscriber SS#: Policy #: Group #: Co-payment for Specialist: Patient s relationship to the subscriber: List secondary payer information: Subscriber: Subscriber SS#: Policy # Group #: Relationship to subscriber: IN CASE OF EMERGENCY Emergency contact name: Relationship to patient: Home phone: Cell phone: I authorize Asthma & Allergy Clinic and/or its collection agents to release any medical information necessary to be submitted to my health insurance carrier for claim processing and adjudication. I grant assignment of benefits to Asthma & Allergy Clinic so payment can be made directly to my provider of Asthma & Allergy Clinic. I also understand that I am financially responsible for any balances not paid by my insurance and finance charges may be applied for charges not paid according to the policies of Asthma & Allergy Clinic or its collection agents. I take full responsibility that the information provided on this registration record is accurate and complete and that I have followed my plans policies regarding authorizations, referrals, pre-certifications or pre-admission authorizations prior to services rendered. I acknowledge that I will be responsible for a $35 no-show fee should I not cancel my appointment 24-hours in advance of my appointment and a $35 returned check fee that will be added to my account and only payable in cash or money order. I acknowledge that I was offered a copy of the HIPAA Notification of Privacy Practices and given an opportunity to ask questions about the information provided. I have read and agree to the terms of the practices financial policies and I certify that I understand the contents of this form. I hereby authorize Asthma & Allergy Clinic to request and use your prescription medication history from other healthcare providers and/or third party payer pharmacy benefits for treatment purposes. I agree to allow Asthma & Allergy Clinic to communicate appointment reminders via my cell phone texting capabilities and/or to leave recording appointment reminders on my home or cell phone numbers. I hereby consent to treatment by Asthma & Allergy Clinic and/or affiliated medical staff members on behalf of my minor child/children and me including stepchildren. I understand that during treatment, the possibility exists for health care workers to become directly exposed to the individual s blood or body fluids. The law authorized the health care providers to test patients for HIV antibodies, deemed consent, when the health care provider is exposed to the body fluids of a patient. In the event of exposure, I understand that I will be deemed to have consented to testing and consent to release test results to the health care worker who may have been exposed. Prior to testing, I will be informed and given the opportunity to ask questions. Patient(s) name please print Date of birth Patient(s) name please print Date of birth 1 3 2 4 Signature of patient/legal guardian Date: Relationship to patient(s)

The Asthma and Allergy Clinic Dr. John R. Sweeney Jr. Md FAAAAI Thamiris V. Palacios-Kibler, DO FAAAAI Alice Wilkins-Bryson, RN MSN FNP 2 Suffolk Office- Phone # (757) 539-7771 Fax # (757) 539-4630 Portsmouth Office- Phone # (757) 483-4150 Fax # (757) 483-7720 *Please plan on spending at least 2 hours at this first visit. Dear Future Allergy Patient: We are looking forward to seeing you soon! I am enclosing some information about our medical practice. I am also enclosing a medical questionnaire which we ask all our new patients to fill out. It is very important that you complete these forms prior to your appointment and bring them with you when you arrive. This information will help our specialists diagnose and formulate a treatment plan for your allergies. In order to do allergy testing, we ask all our patients to please stop taking antihistamines for 3 to 7 days prior to their scheduled appointment. Allergy testing can be an important tool in making a definitive diagnosis as to the cause of your allergies. If antihistamines are in your body s system, the test results may give us a false reading. If you have any questions about any of your medications, please give us a call and one of our nurses will be happy to assist you. Please plan to arrive approximately 15 minutes early for your appointment to allow time for checking-in and new patient processing. Thank you for choosing The Allergy & Asthma Clinic. We will do our very best to help you with your allergies. Sincerely, Your Asthma and Allergy Care Team! Please note our Cancellation Policy, as follows: Notice of cancellation or rescheduling is required no less than 24 hours prior to any scheduled appointment to allow us to give the appointment time to another patient. No-shows, with less than 24 hours notice will be subject to a $35.00 charge.

The Asthma and Allergy Clinic Dr. John R. Sweeney Dr. Thamiris V. Palacios-Kibler Alice Wilkins-Bryson, FNP 3 Payment Policy Thank You for choosing our practice. We are committed to providing you with quality and affordable healthcare. Below is information to answer frequently asked questions regarding patient and insurance responsibility for services rendered. Please read it, ask us any questions that you may have and sign in the space provided. A copy will be provided to you upon request. Thanks so much for being our patient. PAYMENTS ARE DUE AT THE TIME OF SERVICE UNLESS PAYMENT ARRANGEMENTS HAVE BEEN REQUESTED AND APPROVED IN ADVANCE. YOU ARE EXPECTED TO PAY ACCORDING TO THE ARRANGEMENT. Insurance We participate with most insurance plans. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. You or insurance benefit is a contract between you and your insurance company. Referrals If you have an insurance plan which requires a referral, you will need a referral authorization from your primary care physician/ pediatrician. If we have not received a referral prior to your arrival at the office, we have a telephone for you to use to call your primary care /pediatrician physician to obtain it. If you are unable to obtain the referral at that time, you will be rescheduled. Co- payments and Deductible All co-payments- Deductible & Co-insurance must be paid at the time of service. This arrangement is part of your contract with your insurance company and we are contractually obligated to collect them. Proof of Insurance All patients must complete our patient information form before seeing our providers. We must obtain a copy of your driver s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Coverage Changes If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. Methods of Payment We accept payment by cash, check, Visa, MasterCard, and Discover. Patient Statements If you have unpaid balance you will receive a statement by mail every two weeks. The statement amount is due and payable when the statement is issued, and past due if not paid upon receipt. Balances over 90 days will be turned over to an attorney or collection agency for collections. All payments made go to the oldest outstanding balance. No Show Fee Please cancel/reschedule your visits with 24-hours notice. At our discretion, a fee of $35.00 will be charged for a missed appointment. Collection Fees: Balances that have not had a payment made within 90 days will be turned over to collections. Guarantor will be responsible to pay all costs of collections including reasonable interest, reasonable attorney s fees and reasonable collection agency fees not to exceed 33 1/3%. Patient s Name: Responsible Party: Signature: Date: Office Use: Received By: Date:

The Asthma and Allergy Clinic Dr. John R. Sweeney Jr. MD FAAAAI Thamiris V. Palacios-Kibler, DO Alice Wilkins-Bryson, RN MSN FNP 4 Name DOB Date How would you like to be addressed? Mr./Mrs./Ms./Dr. How did you hear about us? Primary Care Physician: Please, describe the reason for the visit today: Referring Physician? Which pharmacy do you use? Phone # HISTORY OF PRESENT ILLNESS: Do you have upper airway symptoms, that you suspect may be caused by allergies? Yes No If Yes, please circle your symptoms: Stuffy Nose: Itchy mouth/ears Loss of Smell Mouth Breathing Runny Nose: Frequent Sneezing Itchy/red/watery eyes Bad Breath Post Nasal drip: Nose Bleeds Difficulty Hearing Loss of Taste Throat Clearing: Snoring Sore Throat Voice Change Itchy Nose: Nasal Polyps Phlegm Nasal congestion Other Symptoms: How long have you had symptoms? What time of the day is worse? AM/PM Worst season of the year: Are symptoms year long? Do you have symptoms when exposed to any of the following triggers? (Please, circle all that apply) Grasses Trees Weeds Molds House Dust Cats Dogs Exercise Windy Temperature changes Stress Smog Smoke Fragrances Chemicals Menstrual Period Strong Odors Alcoholic beverages Spicy Foods Cold Days Have you ever had skin testing? Yes No If yes, how long ago? Have you ever been on allergy injections (desensitization)? Yes No If yes, how long? Have you had sinus infections in the past? Yes No If yes, how often? Have you had an X-ray or CT scan of your sinuses? Yes No If yes, when? ASTHMA Have you ever been diagnosed with Asthma? YES NO If YES, year diagnosed If NO, have you or are you experiencing any of these symptoms? Please, Circle any applicable symptoms Shortness of breath at rest Cough Night time awakenings Chest tightness Shortness of breath with exercise Wheezing Difficulty getting air in/out Phlegm Other symptoms Year of diagnosis Is your activity, including exercise, restricted because of asthma? YES or NO What worsens your breathing symptoms (e.g. cold air, smoke)? What time of the year does your asthma worsen? How frequently do you have asthma exacerbations? How many nights a week/month? How often do you use your rescue inhaler? Have you ever been intubated? Number of ER visits Number of Hospitalizations? Number of missed work/school days How many times have you needed steroids (pills or injections) for asthma exacerbations? Have you had an x-ray or CT scan of your chest? YES NO If yes, when?

5 ECZEMA OR RASHES Do you have eczema? YES NO Location of rash How long have you had the rash: What medicines have you used for the rash? What soaps/lotions do you use? HIVES OR SWELLING Do you have hives or swelling? YES NO Location of the symptoms Please, describe your symptoms How long have you had hives or swelling? What worsens your symptoms? What medicines have you used for the symptoms? Do you have an EpiPen YES NO Have you had a biopsy? OTHER ALLERGIES Do you have a food allergy or suspected food allergy? YES or NO If yes, what foods and what type of symptoms? Have you eaten these foods since then? YES NO If yes, did you have a reaction? Have you ever had a serious or life -threatening reaction to an INSECT STING? YES or NO If yes, what was the reaction? Do you have an EpiPen? YES or NO X. Review of Systems Within the past month, (Please, check all that apply) Const. (Health in General) No Problems, Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, pain in jaws when eating, scalp tenderness, prior diagnosis of cancer. Other: Ears, Nose, Mouth & Throat No Problems Difficulty with hearing, sinus problems, runny nose, post-nasal drip, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds, sore throat, facial pain or numbness. Other: C-V (Heart & Blood Vessels) No Problems Irregular heartbeat, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Other: Resp. (Lungs & Breathing) No Problems Shortness of breath, night sweats, prolonged cough, wheezing, sputum production, prior tuberculosis, pleurisy, oxygen at home, coughing up blood, abnormal chest x-ray. Other: GI (Stomach & Intestines) No Problems Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence. Other: GU (Kidney & Bladder) No Problems Painful urination, frequent urination, urgency, prostate problems, bladder problems, impotence. Other: MS (Muscles, Bones, Joints) No Problems Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Other: Integ. (Skin, Hair & Breast) No Problems Persistent rash, itching, new skin lesion, change in existing skin lesion, hair loss or increase, breast changes. Other: Neurologic (Brain & Nerves) No Problems Frequent headaches, double vision, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, episodes of visual loss. Other: Psychiatric (Mood & Thinking) No Problems Insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions. Other: Endocrinologic (Glands) No Problems Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Other: Hematologic (Blood/Lymph) No Problems Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Other: Allergic/Immunologic No Problems Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV. Other:

6 II. PAST MEDICAL HISTORY: Please list your medical conditions: III. PAST SURGICAL HISTORY: Have you had any of the following surgeries in the past Sinus surgery Tonsillectomy/Adenoidectomy Ear Tube Placement Other surgeries: IV. FAMILY HISTORY: Has anyone in your family ever been diagnosed with any of the following conditions? (Circle all that apply) Hay Fever Food Allergy Asthma Eczema Hives Immunodeficiency Other illnesses: V. IMMUNIZATION HISTORY: Are your immunizations up to date? YES or NO Please list dates of vaccines: Influenza( flu ) Pneumococcal VI. MEDICATION HISTORY: Please, list the medications you are currently taking including prescription drugs, medications used occasionally, over-the-counter medications, vitamins, and herbal supplements below. VII. Drug Allergy: Yes No If yes, please list the name of medication and reaction VIII. SOCIAL HISTORY: Occupation Marital status Educational Level Do you have children?, If so, how many? Hobbies? Do You Smoke? Yes/No If YES, For How Long? How Much? Have You Quit Smoking? Yes No If YES, When? Do You Drink Alcohol? Yes No If YES, How Much? Do You Use Any Other Recreational Drugs? Yes No If YES, please list IX. ENVIRONMENTAL HISTORY Do you live in a house/apt/townhome, duplex, trailer? How old is your home? Do you have any pets? YES NO pets live: Indoors Outdoors Do pets sleep in bedroom? YES NO If yes, what kind and how many? Do the Is there anyone that smokes in your home? YES NO if YES, where do they smoke? INDOORS OUTDOORS Types of trees/greenery around your home? What type of pillows do you use(i.e. feather, down, etc.) Do you have carpet in your bedroom? YES NO If no, what type of flooring? Do you have any upholstered furniture in your bedroom? YES NO What type of window coverings do you have in your bedroom? How long have you lived in Virginia? Where did you live prior to moving to Virginia?