DATE NAME AGE D.O.B. CHIEF COMPLAINT: PRESENT ILLNESS (Dr. Ein will fill this in.)
|
|
|
- Isabel Banks
- 7 years ago
- Views:
Transcription
1 Allergy & Sinus Center Medical Faculty Associates George Washington University School of Medicine Daniel Ein, MD, FACP, FAAAI, FACAAI Richard Nicklas, MD FAAAI, FACAAI Janine Van Lancker, MD DATE NAME AGE D.O.B. LAST FIRST ADDRESS STREET REFERRED BY: CITY STATE MARITAL STATUS: S M W D PHONE BUSINESS PHONE SOC. SEC. # CHIEF COMPLAINT: PRESENT ILLNESS (Dr. Ein will fill this in.) A. PRESENT ILLNESS & ALLERGY HISTORY : Do you experience the following? EYES: [ ] Red or swollen eyelids [ ] Itching [ ] Redness [ ] Swelling [ ] Tearing [ ] Sensitive to light [ ] Burning [ ] Discharge [ ] Dark circles under eyes [ ] Double Vision EARS: [ ] Frequent Infections [ ] Itching [ ] Drainage [ ] Fullness [ ] Popping [ ] Changes in hearing [ ] pain NOSE: [ ] Itching [ ] Sneezing [ ] Discharge (clear, yellow, green ) [ ] Stuffiness [ ] Headache (location) [ ] Can not smell [ ] Mouth breathing [ ] Constant nose rubbing [ ] Bleeding THROAT: [ ] Post-nasal drip [ ] Soreness [ ] Itchy throat [ ] Mucus in a.m. [ ] Hoarseness [ ] No taste [ ] Tonsils removed [ ] Adenoids removed
2 NAME CHEST: [ ] Cough [ ] Wheezing [ ] Pain [ ] Night-time cough [ ] Phlegm (amount color ) [ ] Shortness of breath ( at rest with exertion ) [ ] Palpitations ABDOMEN: [ ] Heartburn [ ] Diarrhea [ ] Milk intolerance [ ] Acid regurgitation [ ] Nausea [ ] Vomiting [ ] Changes in bowel movements URINARY: [ ] Pain or burning [ ] Frequency [ ] Bleeding [ ] Infections ENDOCRINE: [ ] Diabetes [ ] Thyroid Disease HEMO/LYMPH [ ] Swollen glands [ ] Anemia [ ] Easy bruising INFECTIOUS [ ] Fever [ ] Chills [ ] Night Sweats MUSCULOSKELETAL [ ] Pain [ ] Joint swelling [ ] Loss of mobility SKIN: [ ] Itchy patches [ ] Dry skin [ ] Eczema (scaly crusts) [ ] Hives [ ] Swelling (location ) PSYCHIATRIC [ ] Depression [ ] Anxiety [ ] Other: TRIGGERS: Which of the following causes your symptoms? ENVIRONMENTAL [ ] All year around [ ] Spring [ ] Summer [ ] Fall [ ] Winter (specify months) [ ] Animals (cat, dog, etc) [ ] Dust [ ] Fumes [ ] Temperature Changes [ ] After physical activity [ ]Nighttime [ ] Menses (period) [ ] After meals [ ] lying down [ ] Common cold [ ] Weekdays [ ] Weekends [ ] Cold Air [ ] Draft [ ] Indoors [ ] Outdoors [ ] Home [ ] Office [ ] Basement [ ] Beach houses [ ] Muggy weather FOODS [ ] Cheese [ ] Milk [ ] Chocolate [ ] Melon [ ] Mushrooms [ ] Nuts (peanut butter) [ ] Citrus fruits [ ] Bananas [ ] Beer [ ] Wine [ ] Shellfish [ ] Other seafood [ ] soy [ ] egg [ ]wheat [ ] other PHYSICAL AGENTS AND HABITS [ ] Perfumes [ ] Cold [ ] Heat [ ] Cosmetics [ ] Chemicals [ ] Hair Spray [ ] Insecticides [ ] Paints [ ] Newspapers [ ] Cigarettes [ ] Stuffed animals [ ] Central Heating [ ] Air conditioning [ ] Cigarette/cigar/pipe smoke ** ** Who in the family smokes?: [ ] Patient [ ] Spouse [ ] Mother [ ] Father [ ] Sibling [ ] Other If you smoke, how many cigarettes daily? What effect does it have? 1. Have the allergic symptoms become [ ] Worse or [ ] Better with time? 2. How often do the symptoms occur? Asthma, Wheezing: [ ] Once a day [ ] Once a week [ ] Once a month [ ] Once a year Hives: [ ] Once daily [ ] More then once daily [ ] Once a week [ ] Once a month [ ] Once a year Nasal and/or Sinus [ ] Once a day [ ] Once a week [ ] Once a month [ ] Once a year NAME NAME
![Thyroid Disease HEMO/LYMPH [ ] Swollen glands [ ] Anemia [ ] Easy bruising INFECTIOUS [ ] Fever [ ] Chills [ ] Night Sweats MUSCULOSKELETAL [ ] Pain [ ] Joint swelling [ ] Loss of mobility SKIN: [ ]](/docs-images/46/21350812/images/page_2.jpg "Itchy patches [ ] Dry skin [ ] Eczema (scaly crusts) [ ] Hives [ ] Swelling (location ) PSYCHIATRIC [ ] Depression [ ] Anxiety [ ] Other: TRIGGERS: Which of the following causes your symptoms?")
3 B. PREVIOUS ALLERGY TESTING AND TREATMENT Have you ever had any of the following: [ ] Allergy testing, by Dr. Where: [ ] Results: [ ] Allergy shots? For how long? Symptoms improved? Medications tried: Nasal Sprays: [ ] Vancenase [ ] Beconase [ ] Nasocort [ ] Nasalide [ ] Nasonex [ ] Rhinocort [ ] Flonase [ ] Nasalcrom Inhalers: [ ] Proventil [ ] Ventolin [ ] Maxair [ ] Alupent [ ] Severent [ ] Flovent [ ] Azmacort [ ]Vanceril [ ] Beclovent [ ] Aerobid [ ] Tilade [ ] Intal [ ]Advair Oral Medications: [ ] Allegra [ ] Allegra D [ ] Claritin [ ] Claritin D [ ] Zyrtec [ ] Zyrtec-D [ ] Sudafed [ ] Exgest [ ] Duravent [ ] Deconsal [ ] Dura-Tuss [ ] Theophylline [ ] Theo Dur [ ] Uniphyl [ ] Prednisone [ ] Medrol [ ] Singulair [ ] Accolate [ ] Other medications tried: CURRENT MEDICATIONS: PAST MEDICAL HISTORY: HOSPITALIZATIONS: ER VISITS: SURGERIES: SERIOUS ILLNESSES OR TRAUMA: LATEX SENSITIVITY: INSECT STING REACTIONS: LAST CHEST X-RAY LAST PULMONARY FUNCTION ANY ENT EVALUATION? SINUS CT SCAN OR X-RAY? DRUG ALLERGIES AND REACTIONS: FAMILY HISTORY OF ALLERGIES : MOTHER FATHER SISTER(s) BROTHER(s) CHILDREN SOCIAL HISTORY: MARITAL STATUS: YEARS OF EDUCATION:
![] Severent [ ] Flovent [ ] Azmacort [ ]Vanceril [ ] Beclovent [ ] Aerobid [ ] Tilade [ ] Intal [ ]Advair Oral Medications: [ ] Allegra [ ] Allegra D [ ] Claritin [ ] Claritin D [ ] Zyrtec [ ]](/docs-images/46/21350812/images/page_3.jpg "Zyrtec-D [ ] Sudafed [ ] Exgest [ ] Duravent [ ] Deconsal [ ] Dura-Tuss [ ] Theophylline [ ] Theo Dur [ ] Uniphyl [ ] Prednisone [ ] Medrol [ ] Singulair [ ] Accolate [ ] Other medications tried:")
4 STATUS: CURRENT OCCUPATION: HOBBIES OCCUPATIONAL EXPOSURES/GEOGRAPHY: SMOKING: CURRENT: PAST: NAME ENVIRONMENTAL HISTORY: HOME: HOUSE/APT: AGE OF BUILDING): LENGTH OF OCCUPANCY: AIR CONDITION (CENTRAL/WINDOW): HUMIDIFIER (CENTRAL/SEPARATE UNITS): BASEMENT (DAMP, MUSTY, SEEPAGE, FLOODING): BEDROOM (BOXSPRING/MATTRESS, WATERBED): : FLOOR STYLE (WOOD, CARPET( PILLOW (FEATHER/NON-FEATHER): COMFORTER (FEATHER/NON-FEATHER): Is there a lot of stuff in the room? Frequency of cleaning: PETS: DO THEY HAVE ACCESS TO BEDROOM?: DO YOU HAVE ROACHES? WORK: Are you better [ ] worse [ ] or the same [ ] at work as at home? Do you have a separate office? How old is your building? Do your co-workers complain of the air quality? What kind of work do you do? Are you exposed to chemical fumes? How often is the work place cleaned? On a scale of 0 to 10 (10 being total incapacity), how much do your symptoms interfere with yopur ability to function? PHYSICAL EXAM: P BP RESP TEMP HT WGT GENERAL APPEARANCE DATE EYES: CONJUNCTIVAE: SCLERAE: LIDS: NOSE: MUCOSA: SEPTUM: TURBINATES: SINUS TENDERNESS OROPHARYNX: TEETH & GUMS: PN DRIP EARS: TM S: CANALS: NECK: THYROID (ENL/Tend/MASS) LYMPHATICS: NECK AXILLA GROIN EPITROCHLEAR CHEST : PERCUSSION RALES WHEEZING RHONCHI
5 CVS/HEART: PMI: SOUNDS ABDOMEN: SHAPE TENDERNESS MASSES LIVER SPLEEN SKIN: RASH LESION OTHER FLEXURAL ECZEMA: EXTREMITIES: INSPECTION EDEMA PULSES NEURO/PSYCH: ORIENTATION MOOD &AFFECT DIAGNOSIS PLAN 1) 1) 2) 2) 3) 3) 4) 4) 5) 5) FOLLOW UP:
Department of Allergy & Immunology
Department of Allergy & Immunology DR. DATE OF APPT. TIME Dear Patient: Please complete the enclosed questionnaire and bring it with you to the Clinic on the day of your appointment. If you have any questions,
MEDICINES TO CONTINUE TAKING PRIOR TO ALLERGY TESTING
5929 S. Fashion Point Dr. Suite 101, South Ogden, UT 84403 (801) 476-0052 fax (801) 476-0064 The physicians and staff of Intermountain Allergy & Asthma welcome you to our practice! The following information
Allergy Questionnaire. Name: Sex: M F. Contact Info: Home Phone:
Allergy & Asthma Centers of Fredericksburg & Fairfax 9010 Lorton Station Blvd #210 1300 Thornton Street, Suite 200 Lorton VA 22079 Fredericksburg, Virginia 22401 Tel:703-339-1660 Fax:703-372-5567 Tel:540-371-6810
UNIVERSITY OF MISSISSIPPI MEDICAL CENTER D I V I S I O N O F A L L E R G Y A N D I M M U N O L O G Y
For Office Use Only DOV MRN UNIVERSITY OF MISSISSIPPI MEDICAL CENTER D I V I S I O N O F A L L E R G Y A N D I M M U N O L O G Y 768 LAKELAND DR WEST LJ BUILDING 39216 Phone (601) 815-1078 FAX (601) 984-6994
Texas Sinus Center PATIENT REGISTRATION. Name Birth date Soc Sec# Address City/State Zip
Texas Sinus Center PATIENT REGISTRATION 1. PATIENT INFORMATION Name Birth date Soc Sec# Address City/State Zip Home Phone Work Phone Cell Phone Marital Status S / M / W / D Student FT / PT Male / Female
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
Allergy Shots and Allergy Drops for Adults and Children. A Review of the Research
Allergy Shots and Allergy Drops for Adults and Children A Review of the Research Is This Information Right for Me? This information may be helpful to you if: Your doctor* has said that you or your child
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
PATIENT HISTORY FORM
PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your
Emory Eye Center New Patient Questionnaire
Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions
Anaphylaxis: a severe, life threatening allergic reaction usually involving swelling, trouble breathing, and can progress to shock
Allergy is a condition in which the immune system causes sneezing, itching, rashes, and wheezing, or sometimes even life-threatening allergic reactions. The more you know about allergies, the better prepared
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
Name of your Primary Insurance Co:
PATIENT INFORMATION Tufts Med. Ctr. MR # PATIENT NAME: D.O.B. Address: City: State: Zip: Home Phone#: Cell Phone#_ Email address: Gender: // Marital Status: // Social Security # - - Name of Co. /Employer
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE
ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE
Food allergy /anaphylaxis
Food allergy /anaphylaxis A food allergy or hypersensitivity is an abnormal response to a food that is triggered by the immune system. Allergic reactions are often mild, but can be sometimes very dangerous.
Borland-Groover Clinic PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Pharmacy: Pharmacy Phone #:
PATIENT GENERATED MEDICAL HISTORY Name: DOB: Email: Primary Care Physician: Referring: Pharmacy: Pharmacy Phone #: Place Sticker Here Directions: Please circle any of the following you have personally
E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)
E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
Guide to. Allergies 020 8742 7042. A guide to allergies
If you need advice on taking over-the-counter medicines speak to a pharmacist or call the Consumer Health Information Centre s Over-the-Counter Medicines Advice Line on 020 8742 7042. The advice line is
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
Duke Medicine Division of Pulmonary, Allergy & Critical Care Medicine New Patient History Evaluation. Today s Date:
Today s Date: Patient s Name: Date of Birth: Address: Telephone: ( ) Referring Physician: City: Primary Physician: City: Chief Complaint/Primary Reason for evaluation: COPD Bronchitis Cough Asthma Shortness
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
YOU VE BEEN REFERRED TO AN ASTHMA SPECIALIST...
YOU VE BEEN REFERRED TO AN ASTHMA SPECIALIST... ...HERE S WHAT TO EXPECT You have been referred to an allergist because you have or may have asthma. The health professional who referred you wants you to
NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
BROCKTON AREA MULTI-SERVICES, INC. MEDICAL PROCEDURE GUIDE. Date(s) Reviewed/Revised:
Page 1 of 5 PROCEDURE FOR: MAP-certified staff and RN/LPN MAP-certified staff are to be trained in the use of epinephrine administration via pre-filled autoinjector devices(s) annually. Certified staff
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
THE ALLERGIGROUP NEW PATIENT HISTORY PATIENT DATE. Recurrent Infections
Roberto Garcia M.D., P.A. Asthma, Allergy and Immunology Children and Adults Patient Identification ( ) Mr. ( ) Mrs. ( ) Ms. ( ) Male ( ) Female LAST NAME FIRST M.I. AGE D.O.B. Social Security # Address
Antioch College Policy on Food Allergies
Antioch College Policy on Food Allergies Purpose: It is the purpose of this document to inform students and staff the procedures used by the College to identify and provide services for students with allergies
Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1
Edward M. Stroh, M.D., P.C. Retina Consultants of Long Island Page 1 Please fill out completely Legal Name First: Middle: Last: City: State: Zip: Home #: Cell #: Work #: Email: Spouse DOB DOB: Sex: SS
Upper Respiratory Tract (Nose, Sinus, Ear, and Eye) Problems
Colorado Allergy and Asthma Centers, P.C. New Patient History Complete the following information. Please put an X in each box that relates to your problems. Use additional page to answer any questions
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
Rehabilitation Medicine Clinic. New Patient Questionnaire
Rehabilitation Medicine Clinic (Please complete this 5-page form and bring to your appointment.) Date Appt. Date Age Date of Birth Name Male Female Hand dominance: R L Home Address Home Phone ( ) Work
Subject ID: Subject Initials Date completed Interviewer. Person answering questions. 1 yes 2 no
COAST III Childhood Origins of ASThma Asthma Allergy Symptoms COAST 3 year visit Subject ID Subject ID: Subject Initials Date completed Interviewer Person answering questions 99. This form was completed
allergy relief take a deep breath You re protected this allergy season
allergy relief take a deep breath You re protected this allergy season TAKE ACTION AGAINST ALLERGIES It s hard to be at your best when you re suffering from allergies. That s why Rite Aid has partnered
Mold and Moisture-Related Illness Recognition and Management A Key for the Clinician s Office
Mold and Moisture-Related Illness Recognition and Management A Key for the Clinician s Office Patients 1 With any of the conditions listed on Table A. With common 2(possibly non-specific) symptoms that
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
X-Plain Sinus Surgery Reference Summary
X-Plain Sinus Surgery Reference Summary Introduction Sinus surgery is a very common and safe operation. Your doctor may recommend that you have sinus surgery. The decision whether or not to have sinus
Nasal and Sinus Disorders
Nasal and Sinus Disorders Chronic Nasal Congestion When nasal obstruction occurs without other symptoms (such as sneezing, facial pressure, postnasal drip etc.) then a physical obstruction might be the
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
Sinusitis. Health Promotion and Education Program. Rev. 2014 MP-HEP-PPT-766-01-050514-E
Sinusitis Health Promotion and Education Program Rev. 2014 2014, MMM Healthcare, Inc. - PMC Medicare Choice, Inc. Reproduction of this material is prohibited. MP-HEP-PPT-766-01-050514-E M&P-PRD-TEM-030-032511-S
What You And Your Family Can Do About Asthma
GLOBAL INITIATIVE FOR ASTHMA What You And Your Family Can Do About Asthma BASED ON THE GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION NHLBI/WHO WORKSHOP REPORT NATIONAL INSTITUTES OF HEALTH NATIONAL
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
Baylor University Medical Center - Baylor Martha Foster Lung Care Center 4004 Worth St. Suite 300 Dallas, TX 75246 214 820 3500 PATIENT QUESTIONNAIRE
Baylor University Medical Center - Baylor Martha Foster Lung Care Center 4004 Worth St. Suite 300 Dallas, TX 75246 214 820 3500 Please complete this patient self-history form to the best of your ability.
Conjunctivitis - Pink Eye
Conjunctivitis - Pink Eye Introduction Conjunctivitis is often called pink eye. It causes inflammation of the thin, clear lining inside the eyelid and on the white of the eye. The inflammation gives the
that will be helpful to you in your interaction with our office. Please read this prior to your visit.
.) We look forward to your visit with us. We would like to provide you with infonnation that will be helpful to you in your interaction with our office. Please read this prior to your visit. OFFICE HOURS:
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
HOW TO ADVOCATE FOR YOURSELF. Presented by: Melissa Sammons Hughes MD FAAP Lupus Foundation of America, GA Chapter Board of Directors, Former Member
HOW TO ADVOCATE FOR YOURSELF Presented by: Melissa Sammons Hughes MD FAAP Lupus Foundation of America, GA Chapter Board of Directors, Former Member How to Advocate for Yourself Discussion Topics: Keys
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: DATE OF BIRTH: / / AGE: SEX:
REGISTRATION FORM PATIENT NAME: ADDRESS (STREET, CITY, STATE, ZIP): HOME PHONE: WORK PHONE: CELL PHONE: E-MAIL ADDRESS: OCCUPATION: DATE OF BIRTH: / / AGE: SEX: SOCIAL SECURITY NUMBER: MARITAL STATUS:
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
Seasonal Allergies. 1995-2012 The Patient Education Institute, Inc. www.x-plain.com im010101 Last reviewed: 05/30/2012 1
Seasonal Allergies Introduction Seasonal allergies are allergies that develop during certain times of the year. Seasonal allergies are usually a response to pollen from trees, grasses, and weeds. Constant
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Addiction Medical Clinic LLC
Chief Complaint and Symptom: Substance Abused: Current amount per use and Frequency/day used: Last use: Date & Time: Route: Current and in the past: Duration of Use: Both Current and Lifetime: Have you
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
Food Allergies and. Food allergies and the immune system. Food allergies and the immune system
Food Allergies and Intolerances Food allergies and the immune system Food allergies and True allergies involve an adverse reaction/ response by the body s immune system to a usually harmless substance
Allergies: ENT and Allergy Center of Missouri YOUR GUIDE TO TESTING AND TREATMENT. University of Missouri Health Care
Allergies: YOUR GUIDE TO TESTING AND TREATMENT ENT and Allergy Center of Missouri University of Missouri Health Care 812 N. Keene St., Columbia, MO 65201 (573) 817-3000 www.muhealth.org WHAT CAUSES ALLERGIES
Rheumatology Associates of North Jersey New Data Sheet
Personal History Rheumatology Associates of North Jersey New Data Sheet To our new patients: Welcome to our practice. SS: - - Date: Last Name: First Name Date of Birth / / Age Address City State Zip Code
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE
MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.
IMPORTANT: PLEASE READ
PART III: CONSUMER INFORMATION combined hepatitis A (inactivated) and hepatitis B (recombinant) vaccine This leaflet is part III of a three-part "Product Monograph" published when was approved for sale
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
For the Patient: Dasatinib Other names: SPRYCEL
For the Patient: Dasatinib Other names: SPRYCEL Dasatinib (da sa' ti nib) is a drug that is used to treat many types of cancer. It is a tablet that you take by mouth. Tell your doctor if you have ever
Medical Insurance and Vision Plans
Notice of Privacy Practices Methods of Payments No Insurance? No problem! Claremore Eye Associates offers a discount for all non- insurance patients for their vision exam. We also accept all major credit
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
How To Care For A Sick Person
39 How to Take Care of a Sick Person Sickness weakens the body. To gain strength and get well quickly, special care is needed. Medicines are often not necessary. But good care is always important. The
Anaphylaxis. Exceptional healthcare, personally delivered
Anaphylaxis Exceptional healthcare, personally delivered 2 Introduction Anaphylaxis (also known as anaphylactic shock) is a severe, potentially fatal allergic reaction. Anaphylaxis is caused by your body
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
Animal dander: Such as the hair and secretions of pets like cats and dogs.
Allergies Allergic disorders are very common in Australia with approximately 4.1 million Australians¹ having at least one allergy. There are many different types of allergies, presenting with a variety
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
Food allergy and intolerance
Food allergy and intolerance Summary A food allergy occurs when the immune system reacts to a harmless food. Food intolerance occurs when the body has a chemical reaction to eating a particular food or
Swine Flu and Common Infections to Prepare For. Rochester Recreation Club for the Deaf October 15, 2009
Swine Flu and Common Infections to Prepare For Rochester Recreation Club for the Deaf October 15, 2009 Supporters Deaf Health Community Committee Members Julia Aggas Cathie Armstrong Michael McKee Mistie
CONSULTATION & CONSENT FORMS p. 1 of 5 C J HERBAL REMEDIES, INC. ********************************************************************************
CONSULTATION & CONSENT FORMS p. 1 of 5 ******************************************************************************** List your full name, age, sex, and today's date List your complete address List your
MEDICAL HISTORY INFORMATION
MEDICAL HISTORY INFORMATION Name: Birthdate: Age: Address: Home Telephone: Cell Telephone: Work Telephone: Social Security Number: Marital Status: Single Married Divorced Widowed Spouse s Name: Birthdate:
EpiPen Review For Teachers/Staff CONCORD PUBLIC SCHOOLS CONCORD-CARLISLE REGIONAL SCHOOL DISTRICT
EpiPen Review For Teachers/Staff CONCORD PUBLIC SCHOOLS CONCORD-CARLISLE REGIONAL SCHOOL DISTRICT Objectives: Recognize early signs of an allergic reaction State immediate and safe response Administer
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
FLIXONASE ALLERGY Non Drowsy Nasal Spray 24 hour Effective Relief and Prevention Available in 60 & 150 sprays
FLIXONASE ALLERGY Non Drowsy Nasal Spray 24 hour Effective Relief and Prevention Available in 60 & 150 sprays CONSUMER MEDICINE INFORMATION WHAT IS IN THIS LEAFLET? Please read this leaflet carefully before
United States Department of Labor Employees Compensation Appeals Board DECISION AND ORDER
United States Department of Labor L.J., Appellant and DEPARTMENT OF JUSTICE, BUREAU OF PRISONS, Miami, FL, Employer Appearances: Appellant, pro se Office of Solicitor, for the Director Docket No. 12-856
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
Asthma Triggers. What are they and what can be done about them?
Asthma Triggers What are they and what can be done about them? This brochure has been developed for the community by Asthma Australia It provides information about: Asthma triggers What you can do about
Beach Family Doctors Medical Group
Beach Family Doctors Medical Group Welcome to our practice! Office Hours / After Hours 8:30am-5:00pm Monday through Friday; Closed for lunch; Closed all major holidays. For urgent medical issues after
Chemotherapy Side Effects Worksheet
Page 1 of 6 Chemotherapy Side Effects Worksheet Medicines or drugs that destroy cancer cells are called cancer chemotherapy. It is sometimes the first choice for treating many cancers. Chemotherapy differs
EMERGENCY EPINEPHRINE AUTO-INJECTOR DEVICES Policy Code: 5024/6127/7266
EMERGENCY EPINEPHRINE AUTO-INJECTOR DEVICES Policy Code: 5024/6127/7266 Anaphylaxis is a severe systemic allergic reaction from exposure to allergens that is rapid in onset and can cause death. Many severe
Cervical Spine. New Patient Form
Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right
PATIENT REGISTRATION
Evan Wolf, MD PhD Jacob Frank, OD PATIENT REGISTRATION Welcome to our office. In order to serve you properly, we will need the following information. (Please Print) Patient First Name Middle Initial Last
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
Living a Full Life with Fibro 60 Day Action Plan
Living a Full Life with Fibro 0 Action Plan In preparation for a visit to your physician, take the time to complete the 0 Action Plan for fibromyalgia, which can provide you and your physician with a better
CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) 395-6450 FAX (757) 622-2750 INTERNET www.beachpain.com **MEDICATION GUIDELINES PRIOR TO PROCEDURES
CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) 395-6450 FAX (757) 622-2750 INTERNET www.beachpain.com MARTIN V.T. TON, MD Please call us at 395-6450 at least 24 hours in advance if you cannot make
1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
Personal Injury Questionnaire
Personal Injury Questionnaire Patient Information Date Date of Birth Health Insurance Do you have a Flex Spending (FSA) or Health Savings (HSA) Account? Y N Patient Name First M Last What do you prefer