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AAIC Asthma, Allergy & Immunology CenterNew Patient VisitDATE: _________TIME IN: _______TIME OUT: ______ ACCT#: ________Name:___________________________Age: ______Sex: M/FMarried:Date of Birth: ______________Single:PCP/Referring M.D.:__________________Referred by a friend/SelfLocal pharmacy of choice: _______________Mail Order pharmacy: ___________If a minor, accompanied by: (name) _______________________________Reviewed Medical Records from referring Physician/ PCP/ Specialists YES/NODrug Allergies: (Attach list)Food Allergies: (Attach list)__________________________________________________________________________Current Meds: (Attach list)Previous Meds: (Attach list)_________________________________________________________________________________________________________________________________Asthma meds (Circle what applies)Inhalers ______________Nebulizer ____________Singulair ____________Allergy meds (Circle what applies) Nose sprays __________Antihist._____________Eye drops ___________Singulair ____________Meds for Acid Reflux/Heartburn: _________________________________________Meds for Hives/Swelling: _______________________________________________Meds/Creams/Lotions for Eczema/Atopic Dermatitis: ______________________________________________________________________________________________Skin Test/Allergy Blood Test:Date: _______By Whom: ______Allergy shots:__________Stinging Insect _______Fire AntHow long: __________When stopped: _______Shots helping: Y/NPrevious X-rays(Yes/No) CHEST/date: _________SINUS/date: _______Previous CT Scans(Yes/No)CHEST/date: _________SINUS/date: _______NAME: _________________DOB:________ DATE: _____________ ACCT# _______CHIEF COMPLAINTS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________HISTORY OF PRESENTING COMPLAINTS:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________NAME: __________________DOB:_________ DATE: ___________ACCT# _______PAST HISTORY: Circle all that applies:GENERALRECURRENT INFECTIONS NoneRecurrent ear infections? Yes/NoRecurrent sinus infections? Yes/NoRecurrent URI/LRI infections? Yes/No How many per year?____Recurrent pneumonias? Yes/No Recurrent skin infections/ Abscess? Yes/No How many?_________Other infections? _________________________________________________________EAR INFECTIONS:Age of onset:How many per year: ____________Since when:_______________Do infections clear quickly with antibiotics?Yes / NoTubes in Ears: Yes/No(Dates): __________________How many sets: _________Did tubes help? Yes/No Vertigo/Imbalance: How long?__________ Meniere’s Disease: Yes/No Hearing Loss: Permanent /Intermittent. Hearing screening: Yes/No ADENOIDECTOMY/TONSILLECTOMY:Speech: Appropriate / DelayedSpeech Therapy: Yes/NoSINUS INFECTIONS: Age of onset: ______How many per year: _______Do infections clear with antibiotics?Yes / NoSinus/Nasal polyps: Yes/NoSinus surgery / irrigation: Yes/NoHow many times: _________Dates:____________________Name of ENT: ________________ HEADACHES/Migraine : Yes/No Age of onset:______ How often: ____________BRONCHIAL ASTHMA: Age of onset: __________ Well controlled: Yes/NoHave you ever had (circle all that apply)Frequent ER visits: Yes/No Prior hospitalizations/ICU admissions: Yes/NoDate: __________________ Date: __________________Prior intubations: Yes/No Prior oral steroid use: Yes/No Cough / wheeze / short of breath at rest / or with activity: Yes/No Lung Function Tests: Yes/No Date: ______________________By whom: ______________________Aspirin /NSAIDs allergies: Yes/No Nasal/Sinus polyps: Yes/NoPNEUMONIA: How often:___________Please give dates: ____________Right / Left / Both sidesChest x-rays/CT scans# of hospitalizations: ____________ Dates: _____________________NAME: __________________ DOB:___________DATE: _______ACCT #__________*If you have Hives, fill out this page and proceed. If not, just proceed*URTICARIA (HIVES) SKIP THIS SECTION IF YOU DO NOT HAVE HIVESHow long have you had hives? ________________________________________First episode of hives? _________________ Last episode? __________________How often do you break out into hives? _________________________________Where do you break out in hives: Arms/Legs/Hands/Feet/Face/Torso/All overSize of hives: pin-head/dime/quarter/large/irregular/streaks/red: ______________How long do the hives last? Less than 12 hours/less than 24 hours/or several days? ____________________________________________________________What triggers the hives? _____________________________________________Do the hives itch? __________________________________________________Are the hives painful? _______________________________________________When the hives go away, do they leave bruise marks? ______________________Have you had lip, tongue or throat swelling, hand and feet swelling, nausea, vomiting or stomach pain along with the hives? ___________________________What medications have you tried for the treatment of hives: Atarax/ Benadryl/ Claritin/ Zyrtec/ Allegra/ Singulair/ Prednisone/ Pepcid/ Zantac ______________Do you have any body piercings? ______________________________________Have you been to the ER for treatment of hives? __________________________How many times? _______________ Last ER visit: ________________Do you also have: “colds/infections along with hives Cold intolerance/ constipation/ weight gain Fatigue – how long? _________________________________ Joint pain/ muscle pain _______________________________ Any hair loss/ mouth ulcers ___________________________ Large local reactions to mosquito or ant bites _____________Family history of Lupus/ Rheumatoid Arthritis/ Sjogren’s ___________________Recent Blood tests/ Chest or Sinus X-rays / Colonoscopy/ Pap smear/ Mammogram/ PSA/ Skin biopsy/ Patch Test ________________________________________________________________________________________NURSEPhysician NAME: __________________DOB:_________ DATE: ___________ACCT# _______ SURGICAL HISTORY: ________________________________________________________________________________________________________________________________________________________________________________________________________________________HOSPITALIZATIONS: EMERGENCY ROOM VISITS:_________________________ ______________________________ _________________________ _______________________________________________________ ______________________________PSYCHOSOCIAL: (Home situation)________________________________________________________________________________________________________________________________________________FAMILY HISTORY: (circle all that applies) Do parents, grandparents, siblings, or children have the following:AsthmaAllergies Alpha-1 antitrypsin deficiencyChronic infections Eczema/ Atopic Dermatitis EmphysemaSinusitis Immune deficiency Thyroid diseaseCystic FibrosisSarcoidosis Diabetes Hypertension Lupus Rheumatoid Arthritis Heart Disease Cancer Alcoholism DepressionMemory Loss Migraines Travel History: Any recent travel out of state or out of the country_____________________ REVIEW OF SYSTEMS: (Please circle the appropriate answer)GENERAL: Unexplained Weight (gain /loss) Fatigue Unexplained Fever EYES:Itching Watering Burning Redness DryEARS:Popping Itching Ache Fluid PETsImbalance Vertigo Wax DischargeNOSE/ SINUS: BlockingRunningSneezingSniffling Nasal/ Sinus Polyps Nose BleedsAllergy salute Snoring Mouth Breathing/Dryness. Ansomia/Dysosmia Perennial Seasonal –Spring/Summer/Winter/FallTHROAT:PNDItchingSorenessDryHoarseness of VoiceBad breathNAME: __________________DOB:_________ DATE: ___________ACCT# ________ (Please circle all that applies)NECK:Lymph node enlargement / painThyroid gland enlargementHEADACHE:Frontal/Temporal/Top of Head/In between orbits Nuchal Pain AuraTriggers: _______________Pounding/Dull/ThrobbingFrequency: ______________Nausea/Vomiting with headaches? Yes/NoBlurred vision: Yes/NoNight / Early AM / Evening / All dayRelieved with: ___________CT / MRI of head Name of Neurologist: ______CARDIAC:HBPRheumatic FeverHeart murmur / MVPChest painCharacter of pain: Constant / IntermittentRadiation of painRelation to respirationPalpitationsDyspnea/OrthopneaPast ECG or other heart testsName of Cardiologist: ___________________LUNGS:Cough (dry/productive) Sputum: Color _______Quantity: ___________ Blood in sputum ( Y/N)Day: (with activity) / (without activity)Night: when laying downduring sleepearly morningGI:Nausea / VomitingDiarrhea / Constipation Appetite Abdominal painRectal bleedingLiver or gallbladder troubleExcessive belchingGU:PolyuriaNocturiaBladder InfectionsStonesBlood in urineLMP____________MUSCULOSKELETAL: Muscle or joint painStiffness Arthritis BackacheHEMATOLOGIC:AnemiaEasy bruisingPast blood transfusionsENDOCRINE:Thyroid problems Heat / Cold intoleranceDiabetesPSYCHIATRIC:Neuroses Mood SwingDepression Memory LossSKIN: EczemaPoison Ivy Rosacea Dry skin Atopic/Contact Dermatitis HivesNAME: __________________DOB:_________ DATE: ___________ACCT# _______BIRTH HISTORY / INFANT FEEDING/ PEDIATRICS:GESTATIONAL AGE: Term (37-42 wks)Pre Term (<37 wks) Post Term (>42 wks)Complications: ___________________________________________________________Birth weight: __________Length: ________ Nursery Stay:__________ Assisted breathing: ________________________________________________________FEEDING HISTORY: Breast Fed: Yes/NoHow many months? _____________ Formula fed/ supplemented (Yes/No) Milk based formula/Soy formula/Other________________ Allergy to Formula/Baby Food/Table FoodDELIVERY: Normal C-Section Umbilical cord separation: Normal / Delayed (more than 6 weeks)Rash at first month of birth: Yes/NoGrowth and Development: Normal / Delayed(Provide immunization records)Immunizations:Up to dateYes / No - Requires _____________Prevnar /PneumovaxInfluenzaVarivaxENVIRONMENTAL / SOCIAL HISTORY:Alcohol/Drugs:Frequency:Duration of use:House / Apartment / Mobile HomeCarpet: Old / NewLived in for how long? fully / partiallyLocation Rural / UrbanPets: Cats: in/outMattress: EncasedYes / NoDogs:in/outPillows:Feathered/OtherOther:in/outBed Spread:Down/Poly fillHeat:Central Space Heaters Electric / Gas / KeroseneIndoor plants:How manyAir conditioning: Central / WindowFan/Ceiling FansYes/NoFilters changed frequently? Yes/ NoVenetian BlindsDrapes (Light/Heavy)Stuffed Animals? Yes / No If you are a NON SMOKER, SKIP this section.Smoking History:If you are a smoker, please fill out the questions belowTobacco use: ________ yearsSmokes cigarettes? Yes/NoIf yes, how many packs a day? ________Smokes pipe? Yes/NoUses chewing tobacco? Yes/NoSmokes Cigars? Yes/NoSmoke marijuana: Yes/NoNAME: ________________ DOB:___________DATE: _________ACCT #__________Smoking History continued:Have youHave you tried to quit? Y/ N If yes, when did you quit? ___________If not, would you like to quit? Y/ NSecond hand tobacco exposureNoneMinimalFrequentDailyFamily member smokes indoors / in carFamily member smokes outdoors onlyCaregiver smokes indoors / in carCaregiver smokes outdoors onlyOccupation: _____________________Years at current occupation: _______Occupational exposure to Dust/Smoke/Irritants# of work days missed this year: ____________Hobbies: __________________________ Outdoor activities: (_______%)Attending Day Care since_______ How many days a week: _______________# of children in class/group: _________ School Grades: Good/Above Average/Average/Poor# of school days missed this year:________Has your illness impacted your quality of life: Yes/NoIf yes, please explain: ___________________________________________________________________________________________________NurseDate_______________________________________________Prem K. Menon, M. D.Date FAAAAI, FACAAI, FAAP_______________________________________________Vimla Menon, M. D.DateFAAAAI, FACAAI, FAAP ................
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