BOULDER MEDICAL CENTER, P.C.

Similar documents
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

List your current allergy/asthma medications, including over-the-counter medications: Medication Dose How Often?

Telephone Number Home: Work: Cell:

Comprehensive Allergy and Asthma Care Center. New Patient Questionnaire. Patient Name: Age: DOB: Sex: M F

Name: Date: How were you referred? Physician Other Self Referral. What problem brings you or your child to this appointment?

Medical History Form

Allergy/Immunology Questionnaire

THE ALLERGY AND ASTHMA CLINIC

Richmond Office 4718 National Rd. E. Richmond, IN

Patient (Parent) Questionnaire Patient s Name: DOB: Date: Referred By: Primary Care Physician:

NEW PATIENT HISTORY. Patient s Name: Primary Care or Referring Physician:

Please Print When Filling Out This Form

ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #200 MAPLE GROVE, MN TEL (763) FAX (763)

9220 Haven Avenue, Suite 101 Rancho Cucamonga, CA Tel: (909) Fax: (909) ALLERGY HISTORY

ALLERGY CLINIC-PATIENT QUESTIONNAIRE NAME: DOB: TODAY S DATE:

(pedi) Patient Name: date of birth:

PLEASE DO NOT WEAR FRAGRANCES

PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.

THE ALLERGY AND ASTHMA CLINIC

New Patient Questionnaire

New Patient Registration

Adult Allergy & Medical History

ALLERGY CLINIC JOHN V. BOSSO, MD, FAAAAI, FACAAI, DIRECTOR

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.

Pediatric Allergy, Asthma & Immunology Jackee D. Kayser, M.D. Howard M. Rosenblatt, M.D. NEW PATIENT QUESTIONNAIRE

SOUTHWEST ALLERGY AND ASTHMA CENTER, P.A. ALLERGY HISTORY FORM PATIENT S NAME BIRTHDATE APPOINTMENT DATE

Patient Name: Date / Time of Appt: at

Pediatric and Adult Asthma, Allergy & Immunology. New Patient Forms

Name: Date: 1. What is the principal reason for consulting us?

Room # Critical Care & Pulmonary Consultants, P.C.

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):

ALLERGY & ASTHMA SPECIALISTS, P.C.

Mary Maier, MD Board Certified Allergist and Immunologist 2011 NW Myhre Place, Silverdale, WA (360)

Allina Health United Lung and Sleep Clinic

PATIENT INFORMATION. Last Name First Name Address Zip Code City State

HEALTH QUESTIONNAIRE. Do not take antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hours

last name: first name middle initial: date of birth / /

Frequent Ear Infections Past Present Have you had pressure equalization tubes? No Yes If yes, date(s): Ear Symptoms Past Present

Do not take any antihistamines 5 days prior to your appointment Approximate length of appointment: 1-3 hrs

(Continued on next page) PATIENT HISTORY: Date of Birth. Today s Date. What are the symptom(s) that bother(s) you the most?

ASTHMA & ALLERGY CENTER

PATIENT QUESTIONNAIRE DATE: / / PATIENT NAME

child s last name: first name middle iditial: date of birth / /

Date of Birth Sex: M or F Age

ALLERGY QUESTIONNAIRE. Patient Name

DEVOE ALLERGY & ASTHMA CLINIC Phillip W. DeVoe, M.D., PA

Safety Precaution Tips Against Seasonal Allergies (Hay Fever) By: Dr. Niru Prasad, M.D., F.A.A.P., F.A.C.E.P. WHAT IS HAY FEVER?

PUGET SOUND ALLERGY, ASTHMA & IMMUNOLOGY

Initial Pain Management Patient Questionnaire

Does rhinitis. lead to asthma? Does sneezing lead to wheezing? What allergic patients should know about the link between allergic rhinitis and asthma

Asthma & Allergy Clinic REGISTRATION FORM

GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT

Family Allergy Clinic

Allergy & Asthma Consultants, L.L.P. 720 W. 34 th Street Suite 200 Austin, Texas Office (512) Fax (512) PATIENT INFORMATION

Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.

Asthma Assessment & Review

Allergy Clinic of Iowa Advanced Allergy Therapeutics

Cold, Flu, or Allergy?

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

EYE ASSOCIATES OF MONMOUTH, LLC

Office Policy for New Patients

New Life Allergy Treatment Centre Your Natural Solution to Health New Patient Health History

Patient s last name: First: Middle: Birth date: / / HISTORY Reason for consulting the doctor (describe your symptoms and complaint:

Dear Patient, has an appointment

Welcome to our Office

SECONDARY INSURANCE Insurance Name Guarantor* *List person or insured name responsible to ensure

Information and Consent for Administration of Immunotherapy (Allergy Injections)

Your child s name: Today s Date: When was your child s last asthma visit?. If your child has never had an asthma visit, check here:

LEARN ABOUT ANOTHER WAY TO TREAT YOUR ALLERGIES

New Patient Pain Evaluation

Avg PM10. Avg Low Temp

Asthma Triggers. It is very important for you to find out what your child s asthma triggers are and learn ways to avoid them.

Creve Coeur Family Medicine, LLC

STAMPS HEALTH SERVICES Allergy Injection Information

Eczema: also called atopic dermatitis; a chronic, itchy, scaly rash not due to a particular substance exposure

SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD

your triggers? Information about a simple lab test that lets you Know Your IgE.

Please give his or her name, address and phone number: Physician Name: Address: Phone Number: Fax:

ALLERGY & ASTHMA ASSOCIATES PLEASE ARRIVE 15 MINUTES BEFORE YOUR APPOINTMENT TO PROCESS THE PAPERWORK - BRING ALL INSURANCE CARDS

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Patient Intake Form for Allegany Ear, Nose, & Throat

FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA

Breathe Easy. Tips for controlling your Asthma

PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /

1960 FP CENTER FOR SLEEP DISORDERS

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

Southeastern Rehabilitation Medicine Initial (New) Outpatient Information Questionnaire

Glossary of Asthma Terms

9834 Genesee, Suite 223B La Jolla, CA Phone Fax

New Patient Information & Consents

Wisconsin Integrative Pain Specialists

Patient Name First Middle Last Date of Birth Sex M F Age Month Date Year

PAIN MANAGEMENT IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.

You Can Control Your Asthma

Transcription:

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) 440-3083. We look forward to meeting you. Thank you, Karen Andrews, MD Madeline Vogenthaler, NP 2750 Broadway 4745 Arapahoe, Suite 200 80 Health Park Dr, Suite 100 Boulder, CO 80304 Boulder, CO 80303 Louisville, CO 80027

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) 440-3083 FAX 303-440-3100 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

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

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

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

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback