ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #360 MAPLE GROVE, MN TEL (763) FAX (763)

Transcription

1 ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #360 MAPLE GROVE, MN TEL (763) FAX (763) Richard J. Morris, M.D. Thomas J. Helm, M.D. Pramod S. Kelkar, M.D. Name: Date of Birth: Today s Date: Primary physician s name: Primary physician s address: Were you referred to us by a provider? Y/N Referring physician s name (if different): Referring physician s address: Patient- Please fill out this side: The main problems are: PHYSICIAN NOTES YES NO Nasal congestion or sinus pressure Runny nose Itchy or watery eyes Sneezing Snoring Drainage down the throat Frequent yellow or green nasal drainage Ear infections in the past year? How many Sinus infections in the past year? How many Coughing (Complete page 8) Wheezing or shortness of breath Diagnosis of asthma? Age Hospitalizations for asthma? How many Emergency room visits for asthma? How many School/work missed in past year for asthma Night time symptoms of asthma? Per week Rescue inhaler use (Albuterol) Per week Prednisone courses used in the past? How many Reaction to food: yes no (Complete page 6 - one for each food) Bee sting reactions Rashes, eczema, hives etc (Complete page 7) Number of pneumonias during lifetime: Headaches Vomiting, diarrhea, or abdominal pain Transfer of allergy care from Dr. Continuation of allergy shots started years ago Other (explain): These symptoms occur: Spring Summer Fall Winter All the time Best time of year: Symptoms are made worse by: Cats Heat Dogs Cold Exercise Mowing Grass Colds Raking Leaves Cigarette smoke Drugs: Dusting/Cleaning Other: 6/9/15 dh 1

2 All Current Medicines: PHYSICIAN NOTES number of mg, tabs, caps, or inhaler puffs Previous allergy or asthma medications (including OTC): helped no help helped no help helped no help helped no help helped no help Past Medical History: Birth Weight: Problems at Birth? YES / NO Surgeries: (Age or year) for for for Hospitalizations (other than surgery): (Age or year) for for for for Drug Allergies: caused caused Immunization Adverse Reactions: caused caused Past Allergy History: (use space at right if needed) YES NO Previous allergy testing (If yes then answer the questions below) Testing by Dr. Year Previous allergy shots Currently on allergy injections every weeks Do You Have: YES NO YES NO Cats Cigarette smoke Dogs Wood burning stove Birds Damp basement Other pets: Mold growth Feather pillow Room air cleaner Down comforter Whole house air cleaner Bedroom Carpet Workplace: 6/9/15 dh 2

3 Family History: PHYSICIAN NOTES Allergies Asthma Mother Father No. of Sisters No. of Brothers No. of Children Grandmother (s) Grandfather (s) Aunt(s) Uncle(s) Cousin(s) Other chronic family conditions such as cystic fibrosis, emphysema, recurrent hives or swelling, immune deficiency, cancer, diabetes etc: Social History: Current occupation is: If child, primary residence is: one home split between homes Activities: Review of Systems: (check if present) Problem with Growth/Weight Pediatric Developmental Problems Skin Problems Blood Count Problems (anemia, etc.) Eye Diseases (e.g. glaucoma, cataracts) Hearing Problems Thyroid Disorder Lung Disease (other than asthma) Heart Problems or High Blood Pressure Stomach Upset, Heartburn/Reflux Bowel Disorder Liver Disorder Prostate Problem Urinary or Bladder Problems Gynecologic Problems Mental Health Problems Hormone Problems (such as diabetes, menopause, etc.) Bones & Joints Cancer Autoimmune Disease (e.g. Lupus, Rheumatoid Arthritis) HIV Infection Other comments: Name of person filling out this history form (print): Relationship if not the patient: 6/9/15 dh 3

4 FOOD ALLERGY QUESTIONAIRE Please use ONE FORM PER FOOD Name of food When did you eat it last and reacted How much food was eaten What was the reaction How many minutes or hours after eating did the reaction start How long did the reaction last _ How did you treat/manage the reaction How many times have you had the reaction Did you go to the ER Did you try the same food again Which foods are you currently strictly avoiding Do you have Epi-Pen or Auvi-Q Do you have an Anaphylaxis Action Plan What are the goals of your visit today 6/9/15 dh 4

5 Hives/Itching How long have you had it How often do you get it (weekly daily, etc) How long does it lasts once it comes Itching present or not Do you have any pain or burning with hives _ How does it look to you What body parts affected? Is it all over the body? Head/scalp? When it goes away, does it leave any mark behind Are you under high stress Do you take OTC pain killers- like ibuprofen, etc.? How often? What medications have you tried? Did they help? Did you see a dermatologist Did you have any blood tests done Do you have exposure to new contacts, environments or medications Do you have other symptoms like nausea, abdominal pain, fever, weight loss, etc. Do you get lip swelling, face swelling, throat closing? How often? How often have you been to the ER What are the goals of your visit 6/9/15 dh 5

6 COUGH QUESTIONAIRE How long have you had a cough? Is the cough daytime or nighttime or both? Does the cough wake you up at night? Any blood or mucus? Is the cough wet or dry? Have you had a chest xray? If so, when and where? Have you had a CT of the chest? If so, when and where? Have you had a CT of the sinus? If so, when and where? Have you seen any specialists, such as Ear Nose and Throat, Pulmonology (lung) Gastroenterology? Which ones? Which medications have you tried? Do you have heartburn/reflux issues? What triggers your cough? Does it feel to you that the cough is coming from the throat or the chest area? Are you taking any painkillers, aspirin, blood pressure or diabetes medications? Do you snore? What are the goals of your visit today 6/9/15 dh 6

7 ALLERGY AND ASTHMA CARE, P.A ELM CREEK BLVD. #360 MAPLE GROVE, MN TEL (763) FAX (763) Your appointment for a consultation has been scheduled. Please bring along the completed forms and any medications you are presently taking. If you have been receiving allergy injections, please bring a record of these injections. Do not reorder new extracts from your present doctor but bring along any extracts you may currently be using. Patients under the age of 18 years old must be accompanied by a parent or guardian. This evaluation may take a couple of hours; please limit family members attending the appointment. If illness or circumstances prevent you from keeping this appointment, please notify us as early as possible so we may extend this time to other patients. This office has a 24-hour cancellation policy for consultations. Your cooperation is greatly appreciated. PREPARATION FOR ALLERGY TESTING In order to obtain valid and useful skin testing results, you need to discontinue the use of certain medications for a specific time before the skin test and your appointment. 1. All over-the-counter (OTC) antihistamines such as Benadryl, Contac, Dristan, etc; sleep aids such as Nytol, Tylenol PM; and all prescription antihistamine must be withheld for at least 48 hours (2 days) before your appointment. 2. Because most cough preparations contain antihistamines, these must be withheld for 2 days. 3. Specific non-sedating antihistamines such as Allegra, Claritin, Clarinex, Xyzal and Zyrtec need to be withheld for 5 days. Antihistamine nose spray Astelin, needs to be withheld for 5 days. 4. If you have hives, do not discontinue antihistamines. Allergy testing will probably not be done at the first visit. 5. Medicines containing HYDROXYZINE must be stopped for 5 days. 6. Some antidepressants, specifically tricyclic antidepressants (Adepin, Doxepin, Elavil, Nopramin, Trazadone etc.) can affect skin test results and need to be withheld for 2 weeks. Please contact your prescribing physician, before discontinuing these medications. 7. Prescription nose sprays like Nasonex, Nasacort AQ, Rhinocort AQ, Flonase, Fluticasone do not interfere with testing, nor do Singulair tablets. You do not need to stop them before your appointment. Other drugs used for asthma, such as oral prednisone and other cortisone derivatives inhaled corticosteroids (Beclovent, Vanceril, Advair, Azmacort, Aerobid, Flovent, Pulmicort, QVAR) and the metered dose bronchodilators (Albuterol, Maxair, Proventil, Pro-Air, Serevent, Ventolin) will not interfere with skin testing and should be continued. (See back of this sheet for a complete list of medications that should be withheld prior to skin testing.) Additionally, there are no restrictions on diet. If you are unable to restrict these medications as requested or have any other questions, please call us in advance at (763) Thank you for your cooperation. 6/9/15 dh 7

8 Medications Which Must Be Withheld Prior to Skin Testing All the medications listed below must be held at least 48 hours prior to skin testing, and the medications denoted by a * or + must be held longer than 48 hours. The majority of these medications are antihistamines used to treat allergy symptoms or hives. However, the sleep aids and medications used to prevent dizziness or nausea also have antihistaminic effects. If you are taking a tricyclic antidepressant, consult with your doctor before stopping it. These medications are listed by brand name, with the (generic name) in parentheses. Actifed (triprolidine HCL) Disophrol Polaramine, Polargen Alka-Seltzer Plus Cold (chlorpheniramine) Dorcol (dexchlorpheniramine) *Allegra (fexofenadine) Dristan Pyribenzamine Allerest (chlorpheniramine) Drixoral Pyrroxate (chlorpheniramine) *Alavert (loratadine) Extendryl Rhinex *Atarax,Vistaril (hydroxyzine) Fedahist (chlorpheniramine) Rondec (carbinoxamine) ARM Hispril (diphenylpyramine) Rynatan (chlorpheniramine/ Atrohist Histabid pyrliamine) BENADRYL (diphenhydramine) Histadyl Rynatuss Benylin (diphenhydramine) Histaspan Sine-Aid Bromfed (bromphenaramine) Isoclor Sinutab Chlor-Trimeton (chlorpheniramine) Kronafed-A Sinutin (chlorpheniramine) *Claritin (loratadine) Naldecon (phenytolozamine) Sudafed-Plus (chlorpheniramine) *Clarinex (desloratadine) Napril Tacaryl (methdilazine) Clistin (carbinoxamine) Nolahist (phenindamine) Tamine Comhist Nolamine (chlorpheniramine) Tavist (clemastine) Congesprin Novafed A Teldrin Contac Novahistine Temaril (trimeprazine) Coricidin (chlorpheniramine) Optimine (azatadine) Triaminic ((chlorpheniramine) Deconamine Ornade Triaminicin Dehist Ornex Trinalin (azatadine) Dimetane PBZ (tripelennamine) Tussagesic Dimetapp Periactin (cyproheptadine HCL) *Xyzal Disobrom Phenergan (promethazine) *Zyrtec (certirizine) This list is not inclusive and does not include many combination cough/cold syrups, extended release products, or ophthalmic (eye) preparations. Anti-nausea/Antivertigo agents: Antivert, Bonine, DizmissR (meclizine) Emete-Con (benzquinamide) Bucadin-5 (bucitzine) Marezine (cyclizine) Non-prescription sleep aides and miscellaneous: Tylenol PM, Unisom, Nytol, Sominex, Twilite, Quita, Midol-MSF Compazine (prochlorpeerazine) Marmine, Dramamine (dimenhydrinate) Dymenate Tigan (trimethobenzamide) +Tricyclic or Tetracyclic antidepressants (Contact your prescribing doctor before discontinuing) Adepin (doxepin) Nopramin (desipramine) Anafranil (chomipramine) Pamelor (nortriptyline) Asendin (amoxipine) Remeron (mirtazapine) Aventyl (nortriptyline) Sinequan (doxepin) Desyrel (TRAZADONE) Surmontil (trimipramine) Endep (amitriptyline) Tofranil (imipramine) Elavil (amitriptyline) Trabcioak (chlormezanone) Ludiomil (maprodine) Vivactil (protriptylline) Time required to withhold medications * 5 days + 2 weeks Rev 6/2014 6/9/15 dh 8