Patient Information · Medical services provided by Allergy Partners, P.A. New Patient Medical...
Transcript of Patient Information · Medical services provided by Allergy Partners, P.A. New Patient Medical...
Medical services provided by Allergy Partners, P.A.
Patient Information
First ______________________________ MI________ Last__________________________________ Pt.ID #________________
Prefers to be called_______________ Date of Birth ____/_____/______ Age ____ Marital Status: ____________________________
Married/ Single/Divorced/Widowed/Other
Address Primary _______________________________ City _______________________________ State_____ Zip _____________
Alternate Address ______________________________ City ________________________________ State_____ Zip ____________
Phone #1 _________________________ Phone #2 ________________________ Phone #3 _____________________ Home/Cell/ Work Home/Cell/ Work Home/Cell/ Work
Email address __________________________ Preferred method of contact: Letter Phone call Email Other______________
Sex____ SS # ___________________Referring Physician _______________________Primary Care Physician__________________ M F
Preferred Language ___________ Race: _________Ethnicity: _______________________________________________________
Non-Hispanic or Latino/ Hispanic or Latino/ other or Undetermined
Referred by: Physician Self Family/Friend Internet Yellow pages Radio TV Other ____________________________
Occupation_________________________Employer___________________________Is this visit related to a work injury? Y N
Current Pharmacy Name and Location ____________________________________________________________________________
Emergency Contact
Name _______________________ Phone # ______________________ Relationship to patient______________
Responsible Party/Guardian/Guarantor Address Same as Patient
Name__________________________ Address______________________ ______ City________________ State ___ __Zip________
Home# ________________________ Cell # ________________________________ Business # _________________________
SS#___________________________ Patient’s Relationship to Guarantor________________________ DOB ____/____/____ ____
Sex _______ Occupation_________________________________ Employer _____________________________________________
Primary Insurance Information Address Same as Patient
Name of Ins.Co. _______________ ID # _______________________________Group #______________Group Name____________
Policy Holder Name ______________________________DOB ____/____/______Relationship to Patient _____________ _________
Address_______________________ ___ City________________ State_____ Zip________ Phone #___________________________
SS# ______________________ Sex______ Occupation_____________________ Employer _________________________________
Secondary Insurance Information Address Same as Patient
Name of Ins.Co. _______________ID # ______________________________Group# _______________Group Name ____________
Policy Holder Name ______________________________ DOB ____/____/_______Relationship to Patient_____________________
Address____________________________City________________ State. ______Zip_______Phone# __________________________
SS# _______________________Sex_____Occupation____________________Employer____________________________________
List Any Persons to Whom You Will Allow Access of Your Medical Records
Name/Relationship___________________________________Name/Relationship_______________________________________
I hereby authorize the office of Allergy Partners, P.A .to release any information necessary to process any insurance claim for services rendered. I
hereby authorize payment from my insurance company or governmental payor to pay directly to Allergy Partners, P.A. for services rendered.
Regardless of my insurance benefits, if any, I understand that I am financially responsible for the fees for services rendered.
I acknowledge that I have received a copy of Allergy Partners, P.A. Notice regarding Privacy of Personal Health Information (PHI). I understand that
Allergy Partners, P.A. may request a medication history from my pharmacy as part of my treatment plan, and I hereby give my consent for such
requests.
Signature _____________________________Signature_________________________ Date_______________
Patient Responsible Party
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Acknowledgement of HIPAA Privacy Notice and Designation of Disclosure 1. Acknowledgement of Practice’s Notice of HIPAA Privacy. The Notice regarding Privacy of Personal Health Information has
been made available to me. Various copies have been placed in black binders around the waiting room and a copy would be
made for me if I request one.
2. Designation of Certain Relatives, Close Friends and Other Caregivers
a. I agree that the practice may disclose certain of my health information to a family member, close personal friend or
other caregiver, since such person is involved with my health care or payment relating to my health care. In that
case, the Physician Practice will disclose only information that is directly relevant to the person’s involvement with
my health care or payment relating to my health care.
b. I wish to be contacted in the following manner (check all that apply):
Telephone, Written and Fax Communication to Relay Laboratory Results
Home Telephone Number__________________________ Written Communication_____________________
______OK to leave a message with detailed information _____OK to mail to my home address
______OK to leave message/report on Answering Machine _____OK to mail to my office address
______Leave message with a call back number _____OK to fax to this number
c. The following person(s) are not authorized to receive my Patient Health Information:
Print Name_______________________________Relationship________________________
3. We perform medical research at Allergy Partners. Our clinical researchers may look at your health records as part of your
current care or to prepare or perform research. All patient research conducted by us goes through a special process required
by law that review protections for patients involved in research, including privacy. We will not use your health information
or disclose it outside of the practice for research reasons without either getting your prior written approval or determining that
you privacy is protected. Your signature below gives us permission to contact you to discuss possible participation in clinical
research studies.
Signature _____________________________Signature_________________________ Date_______________ Patient/Parent/Guardian Responsible Party
For any patient above the age of 18, still living at home or at college, may we discuss your appointments/treatment/insurance
matters with your parent(s) or guardian?
Signature _____________________________Signature_________________________ Date_______________
Patient/Parent/Guardian Responsible Party
I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my
prior consent. I have read and understand the guidelines of this practice.
Signature _____________________________Signature_________________________ Date_______________
Patient/Parent/Guardian Responsible Party
Allergy Partners provides translation and interpreting services to anyone that needs them.
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New Patient Medical History and Allergy Survey
Please complete this form. It is important for your doctor to know the details about your medical history and allergy symptoms. If you
have any questions about completing this form; please ask the medical office staff.
Name: ____________________________________________ Age _____________ Date _______________
Primary Care Physician’s Name: _______________________________________________
Referring Physician’s Name: __________________________________________________
Chief complaint(s) and onset:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Expectations from this allergy/immunology consultation: _______________________________________________________
________________________________________________________________________________________________________
Do you have any of the following: Asthma Yes____ No____ Uncertain____ Date of Onset________
Exercise induced asthma Yes____ No____ Uncertain____ Date of Onset________
Allergies/hayfever Yes____ No____ Uncertain____ Date of Onset________
Hives/Urticaria Yes____ No____ Uncertain____ Date of Onset________
Rash Yes____ No____ Uncertain____ Date of Onset________
Eczema Yes____ No____ Uncertain____ Date of Onset________
Food allergy Yes____ No____ Uncertain____ Date of Onset________
Drug allergy Yes____ No____ Uncertain____ Date of Onset________
Insect allergy Yes____ No____ Uncertain____ Date of Onset________
Headache Yes____ No____ Uncertain____ Date of Onset________
Anaphylactic reaction Yes____ No____ Uncertain____ Date of Onset________
Other (please describe):
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Allergy evaluation: Have you ever been evaluated by an allergist/immunologist? Yes_____ No_____
Name of previous allergist:_____________________ Date last seen:________________
City/State of previous allergist:_______________________
Have you had any “blood work” to determine if you have allergies? Yes____ No____
Have you ever been “skin tested” to evaluate allergies? Yes_____ No_____ Uncertain______
If “yes”, what were you allergic to (check all that apply):
Trees____ Grasses____ Weeds____ Cat____ Dog____ Dust mites____ Molds____
Cockroaches____ Food____
Have you ever been on “allergy injections/immunotherapy”? Yes_____ No_____ Uncertain_____
If “yes”: When did you start:________________
How long did you receive immunotherapy?________________
Did you find it beneficial? Yes_____ No_____ Uncertain_____
Did you have any significant reactions after injections: No___ Yes___ Describe:________________
Nasal and Eye Allergy Symptoms: Onset of Allergy symptoms (age): _____________
How long have you lived in Las Vegas/Henderson? ______________________
Where have you previously lived? _____________________________________________________________________
Do you have daily symptoms: Yes ____ No _____ Seasonal ______
Are your allergy symptoms getting worse: Yes _____ No ______ Constant_____
What time of year are your allergy symptoms worse (check all that apply):
Spring _____ Summer _____ Fall _____ Winter _____
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Do any particular exposures make your allergies worse (check all that apply):
Cats ____ Dogs ____ Smoke ____ Grass ____ Perfume _____ Strong odors _____
Other allergy triggers: _______________________________________________________________
How is your sense of smell: Excellent____ Good____ Poor____ None____
Do you have discolored nasal discharge? Yes____ No____
If yes, what color and how long have you had it? Color:__________ Onset:__________
Check all allergy symptoms that you have:
Eyes: Itching___ Swelling___ Burning ___ Runny ___ Watery___ Discharge___ Pain___
Ears: Itching___ Fullness___ Popping___ Decreased hearing___ Pain___
Nose: Itching___ Sneezing___ Runny nose___ Congestion___ Stuffy nose___ Obstruction___
Mouth breathing___ Nasal pressure or pain___ Nasal polyps___
Throat: Itching___ Soreness___ Post nasal drip___ Throat clearing___ Swelling___
How many times in a row do you sneeze?___________
Do you currently use a nasal spray? Yes____ No____ Name:________________________
Do you currently use an antihistamine? Yes____ No____ Name:_____________________
Do you ever use nasal saline spray? Yes_____ No_____ Never_____
Do you use nasal saline irrigation? Yes_____ No_____ Never_____
Do you use “Afrin” or other over the counter nasal decongestant spray? Yes___ No___ If “yes”, for how long:________
Have you ever had a CT (CAT scan) of your sinuses? Yes____ No____
If “yes”, Date/results:____________________________________________________
Have you ever had sinus surgery? Yes_____ No_____ If “yes”, when:__________________
Have you been evaluated by an ENT/Otolaryngolagist? Yes___ No___ If “yes”, who and when:__________________
Respiratory: Do you cough? Yes____ No ____ Onset of cough: _______________
Do you wheeze? Yes___ No____ Onset of wheezing:_____________
Have you ever been diagnosed with any of the following:
Asthma: Yes_____ No_____ Age of diagnosis:_____________
COPD: Yes_____ No_____ Age of diagnosis:_____________
Emphysema: Yes_____ No_____ Age of diagnosis:_____________
Pneumonia: Yes_____ No_____ How many times:______ Age of diagnosis:____________
Bronchitis: Yes_____ No_____ Age of diagnosis:_____________
Do you cough at night? Yes_____ No_____ How many times per month:____________
Do you wheeze at night? Yes_____ No_____ How many times per month:____________
Do you cough with activity? Yes_____ No_____ How many times per month:____________
Do you wheeze with activity? Yes_____ No_____ How many times per month:____________
What activities cause you to cough or wheeze (check all that apply):
Walking___ Walking up stairs___ Running___ Exercise___
Do you cough when you laugh? Yes_____ No_____
Have you had a chest X-ray? Yes____ No____ Date/results:________________________________
Have you had a chest CAT Scan? Yes____ No____ Date/results:____________________________
Have you had lung function testing? Yes____ No____ Date/results:__________________________
Do you currently use “Albuterol”? Yes____ No____ Nebulizer____ Meter dose inhaler_____
How many times per week do you use Albuterol?_________
Do you use any other respiratory medications? Yes____ No____
Have you used any of the following medications (check all that apply):
Advair___ Flovent___ Pulmicort___ Asmanex___ Qvar___ Foradil___ Serevent___ Combivent___ Singulair___
Albuterol___Dulera___Symbicort___Alvesco___Xoponex
If “yes”, did any of the medications help your breathing: Yes___ No___ Uncertain___
Which medications helped you the most (check all that apply): Advair___ Flovent___ Pulmicort___ Asmanex___ Qvar___
Foradil___ Serevent___ Combivent___ Singulair___ Albuterol___ Dulera___Symbicort___Alvesco___Xoponex
What triggers your respiratory symptoms (check all that apply):
Upper respiratory infection____ Change in weather___ Exercise___ Cold weather___
Hot weather___ Wind___ Smoke___ Strong odors____ Perfume____ Work related____
Have you ever been intubated or on a ventilator? Yes____ No____
Have you ever been admitted to the ICU or PICU? Yes____ No____
How many times in your life have you been on oral steroids:___________
When was your last course of oral steroids:_________
Have you ever had a “Bone density” study? Yes____ No____
Do you have osteopenia? Yes____ No____ Do you have osteoporosis? Yes____ No____
Do you use a peak flow meter? Yes___ No___ If “yes”, what is your best peak flow (liters/min):_____________
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Eczema: Have you ever been diagnosed with eczema? Yes____ No____ (If “No”, go to next section)
Age at onset of eczema? ___________
Triggers of eczema (check all that apply):
Food allergy____ Milk____ Egg____ Nut____ Cat____ Dog____ Dry weather____ Cold weather____
Grass exposure____ Swimming pool____ Bathing____ Other:_____________________________
Do you use daily moisturizer? Yes______ No______
Do you use a topical steroid? Yes____ No____
Have you ever had a severe skin infection requiring antibiotics? Yes____ No____ How many times? ________
Do you have a dermatologist? Yes_____ No_____ Name of physician:________________________________
Have you been evaluated for food allergy? Yes____ No____
Rash: (If NO rash, don’t complete this section) When did your rash first start?_______________________________________________________________________
On what part of your body did your rash first appear? ____________________________________________________
Has your rash got: Better____ Worse____ No change_____
Does your rash “come and go”? Yes____ No____ Constant______
Describe the circumstances surrounding the onset of your rash:_____________________________________________
What do you think caused your rash? __________________________________________________________________
Does the rash itch: Yes ____ No____ Uncertain_____
What size are the individual rash lesions? ______________________________________________________________
What time of day is your rash worse? AM_____ PM_____ No difference_________
I s there any pattern or cycle that your rash follows? No____ Yes____ Describe:_________________________________
Have you identified any place where your rash is worse? (check all that apply):
Indoors___ Outdoors___ Home___ Work___ School___ Vacation___ No difference___ Other:____________ What medications have
you used to control your rash:
1._______________________________________ Effective____ Not effective____
2._______________________________________ Effective____ Not effective____
3._______________________________________ Effective____ Not effective____
4.Steroids:________________________________ Effective____ Not effective____
Do any of the following factors trigger your rash or make it worse? (check all that apply)
Aspirin___ Alcohol___ Food___ Cold___ Heat___ Hot bath___ Water___ Exercise___ Emotions___
Sunlight___ Exertion___ Sweating___ Vibration___ Medication___ Metal exposure___ Tight clothes___
Have you had any of the following symptoms associated with your rash? (check all that apply)
Excessive sweating___ Diarrhea___ Headaches___ Abdominal cramps___ Fever___ Muscle pains___
Joint swelling___ Joint pain___ Joint stiffness___ Fatigue___
Have you traveled outside of the United States immediately prior to onset of the rash? No____ Yes____ Where:_________
Did you start any new medications prior to the onset of the rash? No___ Yes___ Medication:________________________
Drug Allergy: If “no known drug allergies”, place check next to none and proceed to next section: None_______
Please list all drug allergies, date, and reaction(s)
1.Drug: ________________ Date/Age:_________ Reaction:__________________________
2.Drug: ________________ Date/Age:_________ Reaction:__________________________
3.Drug: ________________ Date/Age:_________ Reaction:__________________________
4.Drug: ________________ Date/Age:_________ Reaction:__________________________
5.Drug: ________________ Date/Age:_________ Reaction:__________________________
6.Drug: ________________ Date/Age:_________ Reaction:__________________________
7.Drug: ________________ Date/Age:_________ Reaction:__________________________
Food Allergy: If “no known food allergies”, place check next to none and proceed to next section: None_______
Please list all food allergies, date, and reaction(s)
1.Food: ________________ Date/Age:_________ Reaction:__________________________
2.Food: ________________ Date/Age:_________ Reaction:__________________________
3.Food: ________________ Date/Age:_________ Reaction:__________________________
4.Food: ________________ Date/Age:_________ Reaction:__________________________
5.Food: ________________ Date/Age:_________ Reaction:__________________________
6.Food: ________________ Date/Age:_________ Reaction:__________________________
7.Food: ________________ Date/Age:_________ Reaction:__________________________
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Do you have an EpiPen or EpiPen Jr? Yes____ No____
Have you ever used your EpiPen or received Epinephrine? Yes____ No____ Uncertain ____
Have you ever been seen in the emergency room for food allergy? Yes____ No_____
Are you familiar with the Food Allergy and Anaphylaxis Network? Yes____ No____
Insect Allergy: Have you ever had a “life threatening reaction” to a stinging insect? Yes_____ No_____
If “No”, proceed to the next section, otherwise:
If “yes”: Date_________ Suspected insect______________ Reaction______________________
Date_________ Suspected insect______________ Reaction______________________
Date_________ Suspected insect______________ Reaction______________________
Do you have an EpiPen or EpiPen Jr? Yes____ No____
Have you ever used your EpiPen or received epinephrine? Yes____ No____ Uncertain____
Have you ever been seen in the Emergency Room for insect allergy: Yes____ No____
Have you ever been on “immunotherapy” for insect allergy? Yes____ No____ Uncertain____
Environmental History: Do you live in a: House____ Condo____ Apartment____ Mobile Home____ RV____ Assisted living____ Other_________
Do you have any pets? Yes____ No____
If “yes”, how many of the following: Cats_____ Dogs_____ Hamsters____ Ferrets____ Birds____ Snakes____
Are the pets allowed inside the bedroom? Yes____ No____
Do you have carpeting in the bedroom? Yes____ No____
Do you use a humidifier? Yes____ No____ Do you use central air conditioning? Yes____ No____
Do you use a HEPA filter? Yes____ No____ Do you use an “Ionic Breeze” or similar? Yes____ No____
How many people live with the patient (number): __________
Who lives with the patient (i.e. mom, dad, wife, etc.): _________________________________________________________
Does anyone who lives with the patient smoke? Yes____ No____
Does anyone smoke in the house? Yes____ No____ Does anyone smoke in the car? Yes____ No____
Birth History: (Only to be completed if the patient is < 10 years old)
Place of birth (city/state):______________________________________
Full term: Yes____ No____ If “No”, how many gestational weeks:____________
Check type of birth: Vaginal birth ________ OR C-Section __________
Birth Weight: _____________
Did the baby stay in the NICU? No_____ Yes_____ If “yes”, for how long?: __________ Ventilator? Yes____ No____
Complications: No ____ Yes____ If “Yes”, please describe:____________________________________________
Breast fed: Yes___ No___ If “yes”, for how long:______________________________________
Formula type: Cow’s milk based____ Soy___ Lactose Free___ Nutramigen___ Alimentum___ Other________________
Age started solid foods:_________________
MEDICATIONS Please list all current medications and reason for taking:
1.___________________________________ Reason for taking: ____________________________________________
2.___________________________________ Reason for taking: ____________________________________________
3.___________________________________ Reason for taking: ____________________________________________
4.___________________________________ Reason for taking: ____________________________________________
5.___________________________________ Reason for taking: ____________________________________________
6.___________________________________ Reason for taking: ____________________________________________
7.___________________________________ Reason for taking: ____________________________________________
8.___________________________________ Reason for taking: ____________________________________________
9.___________________________________ Reason for taking: ____________________________________________
10.__________________________________ Reason for taking: ____________________________________________
Please list all over the counter and herbal/vitamins that you are taking:
1.___________________________________ Reason for taking: ____________________________________________
2.___________________________________ Reason for taking: ____________________________________________
3.___________________________________ Reason for taking: ____________________________________________
4.___________________________________ Reason for taking: ____________________________________________
5.___________________________________ Reason for taking: ____________________________________________
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PAST MEDICAL HISTORY Operations/Surgery (Name and date of procedure)
1.___________________________________________________________________________
2.___________________________________________________________________________
3.___________________________________________________________________________
4.____________________________________________________________________________
5.___________________________________________________________________________
Hospitalizations (Where, reason, date, and length of stay)
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
Medical Problems (Problem and date diagnosed)
1.____________________________________________________________________________
2.____________________________________________________________________________
3.____________________________________________________________________________
4.____________________________________________________________________________
5.____________________________________________________________________________
6.____________________________________________________________________________
7.____________________________________________________________________________
8.____________________________________________________________________________
9.____________________________________________________________________________
10.____________________________________________________________________________
Immunizations: Are your immunizations up to date? Yes____ No____
Have you had a recent influenza vaccine? Yes___ No____ Date of last dose: _____________
Have you had a Pneumovax / Prevnar (Pneumonia) vaccine? Yes____ No____ Date of last dose:__________
Date of last tetanus vaccine: _________________
Social History: (Adults and adolescents) Do you smoke (check all that apply)? Yes____ No____ Never_____ Quit ______
If “yes”, how much do you smoke? __________ packs per day Age started:____________
If you “Quit”, when did you quit? __________ How many years did you smoke? _______
How many packs did you smoke per day (average)?_____________
Are you exposed to “passive smoke” from another household member? Yes___ No___
Do you drink alcohol? Yes____ No____
Average drinks per day: ____________ Type of alcohol: Beer___ Wine___ Liquor___
Do you use “recreational drugs”? Yes___ No___ If “yes”, what type:______________________________________
Do you consider yourself at “high risk” for HIV? No___ Yes___ If “yes”, why:________________________________
Have you ever had a blood transfusion? No___ Yes___ If “yes”, why:________________________________________
Caffeine use (drinks/day):____________
Exercise (times/week): ______________ Type of exercise:________________________________________________
Seatbelt use (%): 100___ 75___ 50___ 25___ Never___
Sun exposure: Frequently___ Occasionally___ Rarely___
Sunscreen use: Frequently___ Occasionally___ Rarely___
Occupation:___________________________________
Exposure to toxic or noxious chemical/substances: No____ Yes____ Describe:__________________________
Social History: (If < 13 years old) Is the patient exposed to “passive smoke” from another household member? Yes___ No___
Seatbelt use (%): 100___ 75___ 50___ 25___ Never___
Sun exposure: Frequently___ Occasionally___ Rarely___
Sunscreen use: Frequently___ Occasionally___ Rarely___
Blood transfusion? No___ Yes___ If “yes”, why: ________________________________________
Daycare: Yes____ No____ If “yes”, age started attending: ____________________________
School: Yes____ No____ Grade:____________ Performance: Excellent___ Good___ Fair___ Poor___
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Immunology Evaluation: Have you ever been diagnosed with a primary immunodeficiency? No___ Yes___ If “yes”, please describe:
_______________________________________________________________
Have any family members ever been diagnosed with an immunodeficiency? No___ Yes___
If “yes”, please describe: _______________________________________________________________
Have you ever been diagnosed with any of the following: (check all that apply)
Pneumonia___ Meningitis___ Osteomyelitis___ Sepsis___ Severe Skin Infection___ Bronchiectasis___
Cystic Fibrosis___ IgA deficiency___ HIV___ AIDS___ Antibody deficiency___ Complement deficiency___
Common Variable Immunodeficiency___ Other: ________________________________________________
How many times have you had pneumonia? _________________ How many per year? ___________
How many sinus infections have you had in your life? _________ How many per year? ___________
How many ear infections have you had in your life? ____________ How many per year? ___________
How many throat infections have you had in your life? __________ How many per year? ___________
Have you ever received intravenous immunoglobin (IVIG) therapy? No___ Yes____
If “yes”, please describe: _________________________________________________________
Have you ever been evaluated for primary immunodeficiency? Yes____ No____
Have you ever been tested for HIV? Yes___ No___ If “yes”, last date and result:_______________________
Family History Are there any members of the immediate family who have asthma, hay fever, eczema, rash, food allergies, drug allergies, insect
allergies, arthritis, recurring and/or frequent infections? Please list and comment.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Are there any hereditary diseases or other disorders that seem to occur frequently in your family (diabetes, emphysema, heart
problems)?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Comments:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Medical services provided by Allergy Partners, P.A.
REVIEW OF SYSTEMS / ENVIRONMENTAL HISTORY
Name:________________________________ Date of Birth:___________________
Reason for today’s visit: ______________________________________________
Do you CURRENTLY HAVE ONGOING /RECURRING PROBLEMS with any of the following:
General Nose Gastrointestinal Neurologic
no problem no problem no problem no problem
failure to thrive nasal congestion heartburn headaches
fever runny nose nausea weakness
chills post nasal drip vomiting seizures
sweats nose bleed diarrhea passing out
poor appetite itching constipation dizziness
fatigue sneezing abdominal pain
malaise bloody stool Mental Health
weight loss Throat jaundice no problem
no problem depression
Eyes hoarseness Musculoskeletal anxiety
no problem difficulty swallowing no problem hyperactivity problem
blurring sore throat back pain behavior problems
discharge oral ulcers joint pain
eye pain throat clearing joint swelling Allergic /Immunologic
itchy itching stiffness no problem
red recurring infections
vision loss Cardiovascular Skin bee sting reaction
watery no problem no problem food reaction
chest pains angioedema latex reaction
Ears palpitations dryness
no problem passing out hives
earache leg swelling itching
ear discharge shortness of breath lying down rash
ringing in ears
decreased hearing Respiratory
ears popping no problem
room spinning around cough
itching chest tightness
coughing up blood
daytime sleepiness
shortness of breath
snoring
wheezing
Housing Foundation Air Conditioning Heating
house basement none none
apartment/condo crawlspace window units wood stove
mobile/ manufactured home slab central central hot air
evaporative cooler kerosene
electric space heater
natural gas
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Indoor Mold Water Damage Pests Smoke Exposure Bedroom
none none none none carpet
AC vents leaky roof roaches parents ceiling fan
bathroom plumbing problems rodents spouse/partner humidifier
window frames musty odors grandparent sleeps in own bed
walls condensation caretaker shares bed
basement water stains other
Bed Outdoor Environment Pets How Many?
crib mattress none none Dog Inside:
standard mattress cattle dogs Dog Outside:
water bed chickens cats Cat Inside:
down pillow/ comforter horses birds Cat Outside:
dust ruffle goats hamsters
stuffed toys farm gerbils
wool blanket rabbits
allergy pillow cover guinea pigs
allergy mattress cover other
pets sleeps in bed
Medical services provided by Allergy Partners, P.A.
Some Medications can interfere with allergy skin testing. In order for us to obtain the most accurate results,
please stop antihistamines used for allergy treatment 5 days prior to New Patient Appointments and prior
to Skin Testing. If you have a question about whether it is safe for you to stop your antihistamine, please contact
your prescribing physician.
COMMON MEDICATIONS CONTAINING ANTIHISTAMINES INCLUDE:
Sedating Allergy Medications (All Forms)
Advil Allergy Carbinoxamine Extendryl
Alahist Chlorpheniramine Ketotifen
AlleRX Clor-Trimeton Palgic
Allergy Relief Medication Diphenhydramine (Benadryl) Polyhistine
Brompheniramine (Bromfed) Doxylamine Tylenol Allergy
Clor-Trimeton
Non-Sedating Allergy Medications (All Forms)
Cetirizine (Zyrtec, Wal-Zyr) Fexofenadine (Allegra) Loratadine (Claritin, Alavert)
Desloratidine (Clarinex) - None x 7 days
Levocetirizine (Xyzal) - None x 7 days
Nasal Sprays
Azelastine (Astelin, Astepro) Dymista Olopatadine (Patanase)
Cough/Cold /Sinus Remedies
Actifed Dimetane Semprex-D
Advil Cold/Sinus Dimetapp Sinutab
Aleve Cold Drixoral Sudafed Cold + Allergy
Alka Seltzer Plus/Cold Norel SR/MD Tanafed
Allerest Nyquil Theraflu (All forms)
BC Cold Powder Pediacare Time Hist
Benylin Cough Percogesic Triaminic (All forms)
Comtrex Phenyltoloxamine Tussionex
Contac Robitussin (many forms) Tylenol Cold+Sinus
Coricidin Rondec Vicks 44 M
Co-Tylenol Rynatan/R-Tannate Zicam
Sleep Aids
Advil PM Doxylamine Nytol
Alertec (Modafinil) Excedrin PM Sominex
Hydroxyzine (Atarax/Vistaril) Night Time Sleep Aid Tylenol PM/Tylenol Sleep
Doxepin (Sinequan)
Anti-Nausea/Vertigo Medications
Chlorpromazine Prochlorperazine (Compazine)
Dimenhydrinate (Dramamine) Promethazine (Phenergan)
Meclizine (Antivert)
Stomach Acid Medications
Cimetidine (Tagamet) Famotidine (Pepcid, Mylanta AR) Ranitidine (Zantac)
Itch Relief Medications
Cyproheptadine (Periactin) Doxepin (Sinequan) Hydroxyzine (Atarax/Vistaril)
Diphenhydramine (Benadryl)
Others
Cyclobenzaprine (Flexeril)
Medical services provided by Allergy Partners, P.A.
Do not use oil, cream or lotion on the back or arms for 24 hours prior to skin testing.
Please call your local Allergy Partners office with any questions about these lists.
Please continue taking all of the following medications as prescribed:
Antibiotics
Antidepressants
Asthma Medications- All
Blood Pressure Medications
Decongestants
Heart Medications
Inhalers
Nasal Sprays- Except Astelin/Astepro/Patanase
Steroids
Thyroid Medications
Do not stop these medications without the approval of your physician.
Medical services provided by Allergy Partners, P.A.
FINANCIAL POLICY
Our commitment is to provide the very best medical care to our patients while recognizing the need to limit services to only those that
are necessary for each patient. To meet this commitment, we recognize the need for a definite understanding and agreement
concerning our patient’s healthcare and the financial arrangements for that medical care. Your clear understanding of our financial
policies is important to our professional relationship. Please contact our billing office regarding any questions about our fees, financial
policies or your insurance coverage and your financial responsibilities
Professional Fees: Our fees for medical services are comparable to other similarly trained physicians in the community and reflect
the complexity of your specific needs, the physician time dedicated to your care, the specialized nature of the doctor’s education and
training and support costs associated with providing and coordinating your care. We will be happy to provide you with detailed fee
information at any time.
Patient Payments: Co-pays, deductibles, services not covered by your insurance plan or outstanding balances are due at the time of
your appointment. Payments may be made with cash, check or credit card. Returned checks will be subject to the fee allowed by state
regulations. Please let us know if you are having a particular financial problem and we will try our best to be understanding. Please
feel free to discuss mutually acceptable payment arrangements with our in house Financial Coordinator or our Central Billing Office.
Insurance Payments: We participate and accept assignment of payment with most major insurance plans in the area. Even though
we may submit insurance claims for you, your insurance coverage is a contract between you and your insurer and you are still
responsible for payments and services regardless of the amount your insurance pays. If your insurance company requires an
authorization or referral, it is the patient’s responsibility to obtain this for the initial visit and for continuation of care.
Additional Fees:
Missed Appointments: Please understand that when you reserve an appointment with one of our physicians, we are making a
commitment to your medical care and this prevents another patient from receiving care at that time. To assist all of our patients with
appropriate access to our physicians we may charge a fee for any office visit appointment cancelled with less than 24 hours’ notice.
Please note this fee is not covered by your insurance company.
Medical Supplies: Please note that certain medical supplies given to you at your visit require an advanced payment from you at check
out. We will submit any charges for medical supplies to your insurance company, and we will reimburse you the payment difference
made by your insurance company.
Medical Forms: The completion of disability forms, attending physician statements and other supplemental insurance forms all
require physician and staff time to complete. Accordingly, a fee may be charged to complete most of these forms. Non-standard forms
may be higher.
Nurse Visit: Please note that if a patient comes in without an appointment to speak to a nurse, depending on the time and complexity
of the visit, there may be a charge for the visit.
__________________________________________________ _________________________________
Signature of Responsible Person Date
Medical services provided by Allergy Partners, P.A.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.
We make a record of the medical care we provide and may receive such records from others. We use these records to
provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you
as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical
practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals
with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected
individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose
your medical information. It also describes your rights and our legal obligations with respect to your medical information.
If you have any questions about this Notice, please contact our Privacy Officer listed above.
This medical practice collects health information about you and stores it in a chart and in an electronic health record/personal
health record. This is your medical record. The medical record is the property of this medical practice, but the information in
the medical record belongs to you. The law permits us to use or disclose your health information for the following purposes:
1. Treatment. We use medical information about you to provide your medical care. We disclose medical information to our
employees and others who are involved in providing the care you need. For example, we may share your medical information
with other physicians or other health care providers who will provide services that we do not provide. Or we may share this
information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test. We may also
disclose medical information to members of your family or others who can help you when you are sick or injured, or after you
die.
2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we
give your health plan the information it requires before it will pay us. We may also disclose information to other health care
providers to assist them in obtaining payment for services they have provided to you.
3. Health Care Operations. We may use and disclose medical information about you to operate this medical practice. For example,
we may use and disclose this information to review and improve the quality of care we provide, or the competence and
qualifications of our professional staff. Or we may use and disclose this information to get your health plan to authorize services
or referrals. We may also use and disclose this information as necessary for medical reviews, legal services and audits, including
fraud and abuse detection and compliance programs and business planning and management. We may also share your medical
information with our "business associates," such as our billing service, that perform administrative services for us. We have a
written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the
confidentiality and security of your protected health information. We may also share your information with other health care
providers, health care clearinghouses or health plans that have a relationship with you, when they request this information to help
them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to
improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their
review of competence, qualifications and performance of health care professionals, their training programs, their accreditation,
certification or licensing activities, or their health care fraud and abuse detection and compliance efforts.
4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. If you
are not home, we may leave this information on your answering machine or in a message left with the person answering the
phone.
5. Sign In Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We
may also call out your name when we are ready to see you.
6. Notification and Communication with Family. We may disclose your health information to notify or assist in notifying a family
member, your personal representative or another person responsible for your care about your location, your general condition or,
unless you had instructed us otherwise, in the event of your death. In the event of a disaster, we may disclose information to a
relief organization so that they may coordinate these notification efforts. We may also disclose information to someone who is
involved with your care or helps pay for your care. If you are able and available to agree or object, we will give you the
opportunity to object prior to making these disclosures, although we may disclose this information in a disaster even over your
Medical services provided by Allergy Partners, P.A.
objection if we believe it is necessary to respond to the emergency circumstances. If you are unable or unavailable to agree or
object, our health professionals will use their best judgment in communication with your family and others.
7. Marketing. Provided we do not receive any payment for making these communications, we may contact you to give you
information about products or services related to your treatment, case management or care coordination, or to direct or
recommend other treatments, therapies, health care providers or settings of care that may be of interest to you. We may similarly
describe products or services provided by this practice and tell you which health plans this practice participates in. We may also
encourage you to maintain a healthy lifestyle and get recommended tests, participate in a disease management program, provide
you with small gifts, tell you about government sponsored health programs or encourage you to purchase a product or service
when we see you, for which we may be paid. Finally, we may receive compensation which covers our cost of reminding you to
take and refill your medication, or otherwise communicate about a drug or biologic that is currently prescribed for you. We will
not otherwise use or disclose your medical information for marketing purposes or accept any payment for other marketing
communications without your prior written authorization. The authorization will disclose whether we receive any compensation
for any marketing activity you authorize, and we will stop any future marketing activity to the extent you revoke that
authorization.
8. Sale of Health Information. We will not sell your health information without your prior written authorization. The authorization
will disclose that we will receive compensation for your health information if you authorize us to sell it, and we will stop any
future sales of your information to the extent that you revoke that authorization.
9. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure
to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to
judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth
below concerning those activities.
10. Public Health. We may, and are sometimes required by law, to disclose your health information to public health authorities for
purposes related to: preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or
neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to
medications; and reporting disease or infection exposure. When we report suspected elder or dependent adult abuse or domestic
violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the
notification would place you at risk of serious harm or would require informing a personal representative we believe is
responsible for the abuse or harm.
11. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight
agencies during the course of audits, investigations, inspections, licensure and other proceedings, subject to the limitations
imposed by law.
12. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the
course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We
may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable
efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a
court or administrative order.
13. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement
official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a
court order, warrant, grand jury subpoena and other law enforcement purposes.
14. Coroners. We may, and are often required by law, to disclose your health information to coroners in connection with their
investigations of deaths.
15. Organ or Tissue Donation. We may disclose your health information to organizations involved in procuring, banking or
transplanting organs and tissues.
16. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order
to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
17. Proof of Immunization. We will disclose proof of immunization to a school that is required to have it before admitting a student
where you have agreed to the disclosure on behalf of yourself or your dependent.
Medical services provided by Allergy Partners, P.A.
18. Specialized Government Functions. We may disclose your health information for military or national security purposes or to
correctional institutions or law enforcement officers that have you in their lawful custody.
19. Workers’ Compensation. We may disclose your health information as necessary to comply with workers’ compensation laws.
For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about
your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or
workers' compensation insurer.
20. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health
information/record will become the property of the new owner, although you will maintain the right to request that copies of
your health information be transferred to another physician or medical group.
21. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If
you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In
some circumstances our business associate may provide the notification. We may also provide notification by other methods as
appropriate.
B. When This Medical Practice May Not Use or Disclose Your Health Information
Except as described in this Notice of Privacy Practices, this medical practice will, consistent with its legal obligations, not use
or disclose health information which identifies you without your written authorization. If you do authorize this medical
practice to use or disclose your health information for another purpose, you may revoke your authorization in writing at any
time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You have the right to request restrictions on certain uses and disclosures of your
health information by a written request specifying what information you want to limit, and what limitations on our use or
disclosure of that information you wish to have imposed. If you tell us not to disclose information to your commercial health
plan concerning health care items or services for which you paid for in full out-of-pocket, we will abide by your request, unless
we must disclose the information for treatment or legal reasons. We reserve the right to accept or reject any other request, and
will notify you of our decision.
2. Right to Request Confidential Communications. You have the right to request that you receive your health information in a
specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to
your work address. We will comply with all reasonable requests submitted in writing which specify how or where you wish to
receive these communications.
3. Right to Inspect and Copy. You have the right to inspect and copy your health information, with limited exceptions. To access
your medical information, you must submit a written request detailing what information you want access to, whether you want to
inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested
form and format if it is readily producible, or we will provide you with an alternative format you find acceptable, or if we can’t
agree and we maintain the record in an electronic format, your choice of a readable electronic or hardcopy format. We will also
send a copy to any other person you designate in writing. We will charge a reasonable fee which covers our costs for labor,
supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary. We may deny
your request under limited circumstances. If we deny your request to access your child's records or the records of an
incapacitated adult you are representing because we believe allowing access would be reasonably likely to cause substantial
harm to the patient, you will have a right to appeal our decision. If we deny your request to access your psychotherapy notes,
you will have the right to have them transferred to another mental health professional.
4. Right to Amend or Supplement. You have a right to request that we amend your health information that you believe is incorrect
or incomplete. You must make a request to amend in writing, and include the reasons you believe the information is inaccurate
or incomplete. We are not required to change your health information, and will provide you with information about this medical
practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we
did not create the information (unless the person or entity that created the information is no longer available to make the
amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and
complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we
may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in
conjunction with any subsequent disclosure of the disputed information.
Medical services provided by Allergy Partners, P.A.
5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made
by this medical practice, except that this medical practice does not have to account for the disclosures provided to you or
pursuant to your written authorization, or as described in paragraphs 1 (treatment), 2 (payment), 3 (health care operations), 6
(notification and communication with family) and 18 (specialized government functions) of Section A of this Notice of Privacy
Practices or disclosures for purposes of research or public health which exclude direct patient identifiers, or which are incident to
a use or disclosure otherwise permitted or authorized by law, or the disclosures to a health oversight agency or law enforcement
official to the extent this medical practice has received notice from that agency or official that providing this accounting would
be reasonably likely to impede their activities.
6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with
respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have
previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these
rights, contact our Privacy Officer listed at the top of this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we
are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised
Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was
created or received. We will keep a copy of the current notice posted in our reception area, and a copy will be available at
each appointment. We will also post the current notice on our website.
E. Complaints
Complaints about this Notice of Privacy Practices or how this medical practice handles your health information should be
directed to our Privacy Officer listed at the top of this Notice of Privacy Practices.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to the U.S.
Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W.,
Washington, D.C. 20201, calling 1-877-696-6775, or visiting http://www.hhs.gov/ocr/privacy/hipaa/complaints/.
You will not be penalized in any way for filing a complaint.
Privacy Officer: Denise C. Yarborough, Esquire
Allergy Partners, PA
1978 Hendersonville Road
Asheville, NC 28803
(T) (828) 277-1300
(F) (828) 277-2499
Email: [email protected]
This Notice is effective September 23, 2013; reviewed March 27, 2017.
Medical services provided by Allergy Partners, P.A.
ACKNOWLEDGEMENT
I, ____________________________ (patient) acknowledge that I have received a copy of
Allergy Partners, P.A. d/b/a _________________________’s Notice of Privacy Practices.
Date: __________________ __________________________________
Patient/Guardian Signature