Richmond Office 4718 National Rd. E. Richmond, IN

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You have an appointment at Allergy & Asthma Care at the following address: Richmond Office 4718 National Rd. E. Richmond, IN 47374 765.966.0390 765.966.3343 You can visit our website at www.allergy-asthmacare.com Please call 765.966.0390 with any questions or concerns.

PLEASE BRING THIS FORM WITH YOU ON THE DAY OF YOUR VISIT Name: DOB: Primary Care Doctor: Referred by: Welcome. What brings you to see us today? When did you take your last antihistamine? 1. ALLERGY / SINUS - Age first noticed Symptoms - check all that apply Runny nose Sinus infections Ears plugged up Wheezing Congestion Sneezing Itchy eyes Chest tightness Itchy nose Change in taste or smell Watery eyes Exercise intolerance Post nasal drip Headaches Coughing List treatments that have helped Treatments that have not helped Triggers - check all that apply Spring Cut grass Exercise Cleaning agents/bleach Summer Raking leaves Laughter Cigarette smoke Fall Other outdoor Stress Perfumes and odors Winter Moldy places Menstruation Foods Year round Dust Pregnancy Medications Weather changes Animals/pets Alcohol Colds/viruses 2. ASTHMA - Age at first diagnosis Symptoms - check all that apply Cough Shortness of breath Throat tightness Wheeze Chest tightness Chest burning Mucous Chest pain Other Number of asthma hospital admissions ever: In the last 12 months: Number of asthma ICU admissions ever: In the last 12 months: Number of courses of oral steroids for asthma ever: In the last 12 months: (in the past 4 weeks) Is your asthma well controlled? Y / N Have you limited your activity due to your asthma? Y / N Missed work due to your asthma? Y / N Woken up at night coughing or shortness of breath? Y / N Maximum number of albuterol puffs in one day: # of days using any albuterol in last month: List treatments that have helped Treatments that have not helped

3. ECZEMA - Age first noticed Frequency: Describe the rash: List any triggers: List treatments that have helped: Treatments that have not helped: 4. HIVES - Age first noticed Frequency: Describe the rash: List any triggers: List treatments that have helped: Treatments that have not helped: 5. FOOD ALLERGIES - describe below Food Age Describe Reaction and Treatment What foods are you currently avoiding? 6. INSECT STING REACTIONS - describe below Insect Age Describe Reaction and Treatment 7. CURRENT MEDICATIONS: please attach list or list all 8. MEDICATION AND LATEX ALLERGIES - please list all previous reactions to medications Medication Age Describe Reaction

9. OTHER MEDICAL HISTORY - check all that apply High blood pressure Diabetes/sugar Thyroid Other Reflux/heartburn Kidney problems Cancer Pneumonia Heart disease Hepatitis or HIV Please list all Surgeries and other medical problems: Infections - Number in lifetime, if more than zero, please describe and give dates Pneumonia Fungal infections Meningitis Sinusitis Skin infections Ear infections Bronchitis Sepsis Other Immunizations - Up to Date? Y / N (explain) Reactions to immunizations, if any Last Tetanus: Flu: Pneumonia: 10. FAMILY HISTORY - if yes, please state who Asthma Eczema Cystic Fibrosis Allergies Hives Cancer Food Allergies Immune Deficiencies Other 11. ENVIRONMENTAL HISTORY - Check all that apply House Basement Carpeting Carpet in Bedroom Townhouse Mold or moisture Wood Floors Feather/down bedding Apartment Gas Heat Cats, # Feather/down pillows Condo Electric Heat Dogs, # Dust mite covers Mobile home Central Air Birds, # Tobacco Smoke City Window A/C Other Animals Other exposures Suburb Wood stove/fireplace Rural Propane heat What is your occupation? Who else lives in your home? Are there any other exposures that you are concerned about? Smoking? Current Age first started - Below list any household members that smoke Quit Ages last quit - Never Average packs per day - 12. OTHER SYMPTOMS - check all symptoms that you have currently Fever Chest pain Abdominal pain Headaches Weight Loss Palpitations Heartburn Dizziness Weight gain Rashes Nausea Vision changes Fatigue Dry skin Vomiting Numbness Muscle aches Blood in urine Diarrhea Depression Joint pain Burning Constipation Anxiety

ALLERGY & ASTHMA CARE, INC. John Seyerle, M.D. Ashish Mathur, M.D. Please Print Patients Name D.O.B. E-mail Address Because we value your right to privacy, we would like to determine how to best handle our telephone communications with you. We routinely call our patients for the following reasons: 1. To Confirm Appointments 2. With Test Results 3. To Respond To Your Questions or Concerns In the event we attempt to contact you and you are not available, what would you like us to do? Leave a message on your answering machine/voice mail Home Phone Number Cell Phone Number Leave the information with: Last Name: Relationship: Last Name: Relationship: First Name: Telephone #: First Name: Telephone#: Do Not leave information about me on an answering machine/voice mail or with another person. Leave a name and telephone number and I will return your call. By signing this form you are letting us know the best way to provide you with your personal health information by phone. If any of this information changes, you are responsible for notifying us, preferably in writing. Signature: Date:

ALLERGY & ASTHMA CARE, INC. Account # Insurance Change Name/Add. Change PATIENT INFORMATION (Please Print) PATIENT NAME (Last) (First) (M.I.) STREET ADDRESS CITY STATE ZIP Birth Date Age Sex Home Ph. ( ) Cell Ph. ( ) Work Ph. ( ) Social Security # Marital Status E-Mail Name/address of Referring M.D. Patient's Employer: Name/Address of Pharmacy INSURANCE INFORMATION (All patient MUST provide policy holder information in this section) PRIMARY INSURANCE: Effective Date: Address: I.D.# Group # Policy Holder Date of Birth: Sex Patient Relation to Policy Holder: Policy Holder's Name: Policy Holder's Employer SECONDARY INSURANCE: Effective Date: Address: I.D. # Group # Policy Holder Date of Birth: Sex Patient Relation to Policy Holder: Policy Holder's Name: Policy Holder's Employer ANY ADDITIONAL COVERAGE? ( ) YES ( ) NO (page 1 of 2)

PATIENT INFORMATION (continued) FINANCIAL RESPONSIBILITY (Person responsible if other than patient) Must be filled out for ALL patients including minors NAME (last) (First) (M.I.) STREET ADDRESS CITY STATE ZIP Birth Date Age Sex Home PH ( ) Cell PH ( ) Work Ph ( ) Social Security # Marital Status Name/Address of Primary Care and/or Referring Physician EMPLOYER IS THERE A THIRD PARTY INVOLVED? (i.e. Work Related, Auto Accident)? ( )Yes ( )NO IF YES, Date of Accident Employer at Time of Accident Please present your insurance card(s) to the receptionist when you have completed this form and sign below. I hereby authorize treatment. I authorize release of any medical information necessary to process this claim. I understand that my medical insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the doctor, and that I am ultimately responsible for medical fees incurred during my care of care of my dependents. I hereby authorize Allergy & Asthma Care, Inc. to apply for benefits on my behalf for covered services rendered by them. I also assign all insurance benefits directly to the doctor. I certify that the information I have reported above is correct and true. I permit a copy of this authorization to be used in place of the original. DATE: X Signature (if minor, please have responsible party sign) (page 2 of 2)

APPOINTMENT REMINDERS Day of your Appointment: Set aside approximately 3 hours for your appointment Eat prior to your appointment Arrive 15 minutes prior to your scheduled appointment time Bring completed Patient Information Form and Patient History Questionnaire Prior to your Appointment: DO NOT STOP taking your ASTHMA MEDICATIONS Seven days prior to your appointment, discontinue taking any medications containing antihistamines Examples of antihistamines: Cold & Sinus Medicines Benadryl Claritin Zyrtec Allegra Helpful information to bring to your appointment: List of Medications you are taking Records pertaining to your visit concerning allergies or asthma List of questions you have for the doctor Name/Address of physicians you see Insurance Card(s) Clothing: Skin testing could be applied to your lower arms and it would be helpful if you could wear short sleeves. Billing: Co-pay/co-insurance will be collected at time of service Deductable: if deductable has not been met, be prepared to pay a percentage Payment: we accept Cash, Check, MasterCard, Visa and Discover Questions: Any questions or concerns you may have about your insurance, please call our Insurance Department (1.513.671.0799) during regular business hours. We look forward to providing you with quality healthcare. John Seyerle, M.D. Ashish Mathur, M.D. Allergy & Asthma Care, Inc. Staff

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