Asthma & Allergy Institute of Michigan Jeffrey M. Bruner, D.O., P.C. Angela M. Iacobelli, M.D Garfield, Clinton Twp., MI

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1 Asthma & Allergy Institute of Michigan Jeffrey M. Bruner, D.O., P.C. Angela M. Iacobelli, M.D Garfield, Clinton Twp., MI Field of Clinical Allergy New Patient Information The specialty of clinical allergy is complex and requires thorough and time consuming attention to detail. It is the desire of this office to provide our patients with the most comprehensive allergy care available. We try to deliver care to our patients in a friendly and efficient environment. Your appointment is for, 20 at a.m./p.m. The initial allergy consultation requires approximately two hours. During the initial consultation, a detailed history will be obtained and an adequate physical exam will be performed. If indicated, allergy skin testing is typically performed at the initial consult. If necessary, pulmonary function testing and lab work may also be performed. In order to facilitate obtaining a complete and accurate history, please complete the enclosed questionnaire and bring it to the initial consultation. By sending you this allergy questionnaire for completion, we hope to provide you with ample time to give each question thoughtful consideration. It is also recommended that any pertinent outside medical records be obtained and brought to the consultation (including X-rays, CT scans, outside blood work, or allergy testing). At the initial consultation, the significant findings and test results will be summarized and an initial course of action will be recommended. On some occasions, the entire allergy evaluation may require several visits. When the entire allergy workup is completed, the doctor will summarize all the findings, test results, and review recommendations. Fees and Insurance Payment is expected when medical services are rendered. There is a $5 fee each month for unpaid balances. Please bring all completed insurance forms with you. Although we participate with several insurance plans, not all insurances cover allergy testing or treatment. We recommend that all patients contact their insurance and verify allergy testing coverage. If lab procedures are performed, we will forward your insurance information directly to the lab. The lab will then bill your insurance for payment. If a lab procedure is not covered by your insurance, you will receive a bill directly from the lab. IMPORTANT: If your insurance requires a referral, it is your responsibility to obtain the referral from your primary care physician. Without a referral we will have to reschedule your appointment. NOTE: Your primary care physician must authorize every visit to our office as well as any performed procedures. DIVORCED PARENTS: Patients under the age of 18 years of age must be accompanied by an actual parent or legal guardian. If a stepparent will be bringing the chills in for an office visit or consultation, a signed release must be sent. PATIENTS 18 YEARS OF AGE OR OLDER: Due to office policy and legislation (HIPPA law), patients must sign a release for the office to speak with a parent, spouse, or anyone other than the patient. 1

2 Skin Testing Skin testing is essentially painless. If your child is to be tested, we will be happy to demonstrate the procedure to you. There are two types of skin tests which are helpful in determining the offending allergens: scratch tests and intradermal tests. Before applying scratch tests, the skin (usually the back) is cleansed with alcohol and allowed to dry. Different types of liquid diluted allergens are dropped on the back and then a special instrument is used to slightly scratch the skin. After minutes, the allergen test drops are wiped off the surface of the skin and each test site is checked. The reaction of the skin is then noted to each allergen. A positive reaction consists of a raised, red, itchy welt that will clear up in less than 30 minutes. Scratch tests are usually performed first. The number of scratch tests may vary from only a few to over 50 (depending on the information that is required). Subsequently, if scratch test results need clarification or if no positive results occur, intradermal tests are performed. Intradermal tests are more sensitive tests that involve the injection of a small amount of allergen material into the skin. In 15 or 20 minutes, the allergen test is checked and the reactions are noted. The number of intradermal tests performed is usually less than 20. We ask our patients to refrain from taking antihistamine medications (allergy medications) for a period of 4 days prior to the initial visit since these medications interfere with skin testing results. If it is not possible to stop the medications because of the severity of your symptoms, please notify the office prior to your first visit. Corticosteroids may be continued and do not interfere with allergy scratch or intradermal tests. If there are any questions, please call the office DO NOT TAKE ANY OF THESE MEDICATIONS 4 DAYS PRIOR TO YOUR VISIT: Actdil Atrohist Deconamine Fedahist Periactin Sudafed Plus Antihistamine Actifed Axid Dimetane Fexofenadine Phenergan Tagamet Advil PM Benadryl Dimetapp Hydroxyzine Polyhistine D Tavist Allegra Benylin Doxepin Nolahist Ranitidine Triaminic Allerest Chlor-Trimenton Dramamine Nyquil Rondec Tylenol PM Aleve PM Cimetadine Drixoral Omnihist Ru-Tuss Vistaril Antivert Comhist Dura Vent DA Patanase Rynatan Zaditor Eye Drops Astelin Comtrex Efidac-24 Pataday Rynatuss Zantac Astepro Contac Elavil Patanol Sinequan Atarax Coricidin Extendryl Pepcid Sinutab STOP THESE MEDICATIONS AT LEAST 7 DAYS PRIOR TO YOUR VISIT: Alavert Claritin Zyrtec Cetirizine Claritin D Zyrtec D Clarinex Loratadine Xyzal PRESCRIPTION AND OVER THE COUNTER EYE DROPS MAY ALSO CONTAIN ANTIHISTIMINES (EG. ZADITOR, OPTIVAR, PATANOL, BREPREVE, PATADAY, ELESTAT ETC.) STOP EYE DROPS 4 DAYS PRIOR TO TESTING. ZANTAC, PEPCID, AXID, TAGAMENT ARE TYPES OF ANTIHISTIMINES USED TO TREAT GASTRITIS AND HEARTBURN. THESE MEDICATIONS SHOULD BE STOPPED 4 DAYS PRIOR TO TESTING. NOTE: ASTHMA MEDICATIONS SHOULD NOT BE STOPPED PRIOR TO ALLERGY TESTING (SINGULAIR, ACCOLATE, ZYFLO, OR ANY ANTI-INFLAMMATORY MEDICATIONS) SOME ANTIDEPRESSANTS CAN INTERFERE WITH ALLERGY TESTING. PLEASE DO NOT STOP ANY DRUGS WITHOUT CONSULTING THE PRESCRIBING PHYSICIAN. WE WOULD LIKE TO THANK YOU IN ADVANCE FOR CHOOSING OUR OFFICE. PLEASE FEEL FREE TO CONTACT US AT WITH ANY QUESTIONS OR CONCERNS. 2

3 Asthma & Allergy Institute Of Michigan Jeffrey M. Bruner, D.O., P.C. & Angela M. Iacobelli, M.D. Pediatric and Adult Allergy & Immunology Bronchial Asthma Garfield Clinton Township, MI (586) Allergy Questionnaire Please bring this completed form with you on your first visit. Name Date Please fill in the blanks and circle other applicable answers, feel free to make any additional comments. Base your answers on your own observations and not on what you have been told by others or what you may know about previous skin tests. Though these questions are rather detailed, the information provided will be of major assistance in helping you. If any question is not clear, leave the answer blank and put a check mark in the left hand margin. All information will be considered confidential. DO NOT TAKE ANY HAY FEVER OR ASTHMA MEDICATION FOR 4 DAYS PRIOR TO YOUR VISIT TO THE OFFICE, unless you are taking steroids (cortisone), fluticasone (Flovent or Advair) which may be continued. However, if you are too ill to stop your medications, please continue to take them. Symptoms (Do you have any of the following? If so, please circle. Place approximate onset by month and year, if known, beside each of the symptoms you circle). EYES Itching Burning Tearing Swelling Redness Discharge NOSE Itching Runny Stuffy Sneezing EARS Itching Fullness Popping Drainage THROAT Itching Postnasal Drip Mucus in Morning CHEST Wheezing Tightness Coughing SKIN Hives Eczema Shortness of Breath Loss of Smell Frequent Infections Pain Discharge Circle months when symptoms present: All Year January February March April May June July August September October November December Inhalants: DUST: Does exposure to house dust make your symptoms worse? Yes No What are symptoms? Are your symptoms worse during winter? Yes No 3

4 ENVIRONMENTAL SURVEY: Are your symptoms worse in certain areas of your house? Yes No If so, where? Type of home Age of house years Occupied years Is your house located near a (please circle) Field Forest Lake River Farm Type of heating system: Forced air gas or oil Do you have: Humidifier Yes No Hot water Steam Space Heater Air conditioning Electronic air cleaner Yes No Yes No Your Bedroom: (Please Circle) Rug Type Shag Short Pile Throw None Mattress Type Foam Rubber Feather Cotton Age Pillow Type Foam Rubber Feather Dacron Age Basement: (Please Circle) None Dry Damp Finished Unfinished Musty Smell? Yes No Is there a dehumidifier? Yes No MOLDS: Are your symptoms worse after exposure to the following: Hay Yes No Cutting Grass Yes No Barns Yes No Raking Leaves Yes No Damp Basements Yes No DANDERS: Do you have animals in your home? Yes No If so, what type? Do you have symptoms from any animals? Yes No If yes, what animals and what symptoms? 4

5 MISCELLANEOUS: Do you have symptoms after exposure to the following? Cosmetics Yes No Insectisides Yes No Perfumes Yes No Paint & Varnish Yes No Hair Sprays Yes No Soaps & Detergents Yes No Chemicals Yes No Wool Yes No Newspaper Yes No Cooking Odors Yes No Aerosols Yes No Others Smoking Yes No PHYSICAL AGENTS: Are your symptoms affected by the following? Heat Worse Better No Change Temperature Change Worse Better No Change Cold Worse Better No Change Weather Changes Worse Better No Change Drafts Worse Better No Change Increased Humidity Worse Better No Change Exercise Worse Better No Change Air Conditioning Worse Better No Change Any flare of symptoms with upper respiratory infections (colds)? Yes No Are your symptoms worse at work? Yes No Specific Job: Do you have any hobbies? Yes No If so, list: Are your symptoms better away from home (vacations, etc.)? Yes No Are your symptoms worse away from home (vacations, etc.)? Yes No FOODS: Do any foods make you worse? Yes No If so, which ones, and what symptoms are produced? Have any special allergy diets been tried in the past? Yes No Type of diet and conclusions reached? Do you have symptoms from eating (please circle) Cheese Mushrooms Beer Wine Do you have symptoms from eating melons? Yes No 5

6 RASHES from contactants: Poison Ivy Yes Never Clothing Yes Never Poison Sumac Yes Never Metals Yes Never Poison Oak Yes Never Hobbies Yes Never Other Plants Yes Never Household Agents Yes Never Work Yes Never Adhesive Tapes Yes Never Ointments Yes Never Soap Yes Never Cosmetics Yes Never Latex Yes Never Have you ever had hives? Yes No If so, what was the cause, if known? Have you ever had any reactions to medications? Yes No If yes, please list medications and type of reaction Have you ever had any reactions to insect stings or bites? Yes No If yes, what insect and type of reaction IMMUNIZATIONS: (Please circle appropriate answer and check off in right hand margin if given in past year.) DPT Received Adverse Reaction Polio Received Adverse Reaction Small Pox Received Adverse Reaction Measles Received Adverse Reaction Influenza (Flu) Received Adverse Reaction Mumps Received Adverse Reaction Tetanus Received Adverse Reaction Horse Serum Received Adverse Reaction Blood Transfusions Received Adverse Reaction Gamma Globulin Received Adverse Reaction HABITS: (Fill in the blanks) Average hours of sleep per night Smoker/Non-Smoker Drink/Do not drink Packs per day Cigars per day Years smoking Bottles of beer per week Glasses of wine per week Other alcoholic beverages per week 6

7 SYSTEM REVIEW: Do you now, or have you had: (Please Circle) GENERAL HEAD Fatigue Yes No Frequent or severe head aches Yes No Chills Yes No Acne Yes No Fever Yes No Patchy loss of scalp hair Yes No Dizziness Yes No Fainting Yes No Sweats Yes No EYES EARS Blurred Vision Yes No Pain Yes No Double Vision Yes No Hearing difficulty Yes No Spots before eyes Yes No Hearing loss Yes No Pain behind eyes Yes No Ringing Yes No Pain above eyes Yes No Recurrent infections Yes No Pain below eyes Yes No Infected eyes Yes No Any change in vision Yes No Glasses last checked NOSE THROAT Frequent colds Yes No Frequently sore Yes No Mouth breathing Yes No Voice change Yes No Recurrent Sinusitis Yes No Difficulty swallowing Yes No Loss of smell Yes No Frequent infections Yes No CHEST Coughing up blood Yes No Recurrent pneumonia Yes No Night sweats Yes No Shortness of breath when Walking several blocks Yes No Walking one flight of stairs Yes No Lying down Yes No Aware of heart beating Yes No GASTROINTESTINAL Appetite: Excessive Good Fair Poor Weight: Gain Loss How much? Nausea Yes No Blood in vomitus Yes No Vomiting Yes No Recurrent belching Yes No Diarrhea Yes No Recurrent abdominal pain Yes No Constipation Yes No Fatty stool Yes No Blood in stool Yes No Worms Yes No GENITO-URINARY BONES & JOINTS Difficulty passing urine Yes No Swelling Yes No Pain on passing urine Yes No Deformity Yes No Frequently passing urine Yes No Arthritis Yes No Inability to hold urine Yes No Varicose veins Yes No Blood in urine Yes No Phlebitis Yes No Neuritis Yes No Swelling of feet Yes No 7

8 FAMILY HISTORY and PAST MEDICAL HISTORY: Have you or has anyone in your family (grandparents, mother, father, sisters, brothers, sons, daughters, aunts or uncles) had: (Please Circle) WHO? Anemia Yes No Polio Yes No Asthma Yes No Severe reactions to insect bites Yes No Cancer Yes No Typhoid Yes No Diabetes (sugar) Yes No Mumps Yes No Epilepsy Yes No Cystic Fibrosis Yes No Glaucoma Yes No Chicken Pox Yes No Gout Yes No Scarlet Fever Yes No Hay fever or other Yes No Allergic Skin Rashes Yes No nasal allergy Heart Trouble Yes No Gonorrhea Yes No High Blood Pressure Yes No Liver disease Yes No Hives Yes No Angiodema Yes No Immune Deficiency Yes No Other Health Problems Yes No Kidney or bladder Yes No Syphilis Yes No trouble Migrane Yes No Arthritis Yes No Mononucleosis Yes No Jaundice Yes No Nervous breakdown Yes No German measles Yes No Pulmonary Embolism Yes No Other serious illness Yes No Seizures Yes No Measles Yes No Stroke Yes No Rheumatic fever Yes No Thyroid problem Yes No Diphtheria Yes No Tuberculosis Yes No Pneumonia Yes No WHO? List any operations you have had, and the year performed: List any other hospitalizations and year: List any conditions for which you are currently being evaluated or treated: WOMEN ONLY Menstrual History Age of onset Date last period started Difficulties w/ periods? Yes No Are you on Birth Control Pills? Yes No Number of pregnancies Number of children Were any illnesses or allergic symptoms made worse or better during pregnancy? Yes No If yes, describe Is there any other pertinent information about exposure to environmental allergens that you can give us? Please list all medications you are presently taking: PLEASE BRING THIS FORM WITH YOU TO THE OFFICE AS WELL AS ALL THE MEDICATIONS YOU HAVE BEEN TAKING. REMEMBER, DO NOT TAKE ANY ALLERGY OR COLD MEDICATIONS FOR 4 DAYS PRIOR TO YOUR VISIT. THANK YOU. Please Sign 8