Fillable Language 1 Female

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Language 1 Female

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  • 259 check-boxes
  • 132 other fields

Country of origin: OTHERS
File type: PDF

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Patient’s Name: _______________________________
Spouse’s Name: ___________________________________
Address: ______________
_______________________
Address:
__________________________________________
City: ______________________State: ____ Zip: ______ City: ____________________ State: _____ Zip: ________
Date of Birth: _______/_________/_____________
Date of Birth: ______/____
_____/_____________
Male Female Male
Female
Race: ______________ Ethnicity: ________________ Occupation:
______________________________________
Language 1
st
: ______________ 2
nd
: ______________
Employer:
________________________________________
Home Phone:
__________________________________ Address: __________________________________________
Work Phone:
___________________________________ City: ____________________ State: _____ Zip: ________
Cell Phone:
____________________________________
Cell Phone:
______________________________________
Email: _________________________________________
Occupation:
___________________________________
If the patient is a minor (under 18) please complete:
Employer: _____________________________________ Father’s Name: __________________________________
Address:
_______________________________________ Address: __________________________________________
City:
____________ State: _______ Zip: __________ City: ____________________ State: _____ Zip: _______
Home Phone:
_____________________________________
Work Phone:
_____________________________________
Family Doctor/Pediatrician:
Cell Phone:
_______________________________________
Address: ______________
_______________________ Date of Birth: _______/_________/_____________
City:
_____________________ State: ____ Zip: ______
Occupation: ___________________________________
Phone: ____________________________________
Employer: _____________
________________________
Mother’s Name:
______________________________
Pharmacy: _________________________________
Address: _____________________________________
Address:
_______________________________________
City:
____________________
State:
_____
Zip:
_______
City:
____________________
State:
_____
Zip:
______
Home Phone:
Phone:
_________________
Fax:
_________________
Work Phone:
______________________________________
Cell Phone:
_______________________________________
Date of Birth: _______/_________/_____________
Who is the subscriber on the patient’s insurance?
Occupation:
______________________________________
Self Spouse Father Mother
Employer:
________________________________________
How did you hear about us? _____________________________________________________________________
If referred, who referred you? ____________________________________________________________________
PATIENTS UNDER AGE 18 MUST BE ACCOMPANIED BY A PARENT OR DESIGNATED ADULT IN ORDER TO BE SEEN.
In order to provide a high quality initial assessment, we schedule a lengthy first appointment for our new patients. If you are
unable to keep this scheduled appointment, we require a 24 hour cancellation notice. If a cancellation notice is not given 24
hours in advance, a $40.00 administrative fee will be charged.
The patient is re
sponsible for:
• Co-pays, deductibles and all non-covered items and charges are the insured/patient’s financial responsibility and are
due during the check-in process. Failure to produce payment at check-in may result in your appointment being rescheduled.
• All outstanding balances that are over 30 days old, will incur a monthly statement processing fee, in addition to the initial
balance.
• We accept cash, check and credit card. (Visa, MasterCard and Discover) OFFICE USE ONLY:
All information reviewed by:
PLEASE DO NOT WEAR FRAGRANCES _______________________
____________________
Patient Name:
2
Please list the name and dates of all medications you have tried for this: ________________________________________
_________________________________________________________________________________________________________
_____
____________________________________________________________________________________________________
_________________________________________________________________________________________________________
EVALUATION FOR ASTHMA:
At what age were you diagnosed with asthma? ______________________________________________________________
Have you had any hospitalizations or ER visits for asthma? Yes No
If yes, list approximate dates: ______________________________________________________________________________
Have you been treated with steroid pills for asthma? Yes No
If yes, how often? ____________________ When was
the last time?_________________________
Have you been prescribed any of the following inhalers? Advair Symbicort Dulera Flovent
Asmanex QVAR Pulmicort Alvesco Aerobid Azmacort
What symptoms of asthma do you experience?
Cough Wheeze Shortness of breath Chest tightness
How many days per week do you experience these symptoms?
________________________________________________
How many days per week do you use a rescue inhaler?
______________________________________________________
How many nights per month does your asthma hinder your ability to sleep?
____________________________________
What triggers your asthma? Exercise Laughter Crying Cold Heat Respiratory infections
Change of seasons Pollens Animals Dust Mold Strong smells (tobacco, perfumes, detergents, etc.)
EVALUATION FOR HAY FEVER:
Check the following symptoms that affect you: Sneezing Runny nose Stuffy nose Post nasal drip
Itchy eyes Itchy ears Itchy nose Itchy throat Watery eyes Swollen eyes None
When do these symptoms bother you?
All year long Certain months only (list): _________________________
What exposures make these symptoms worse? Indoors Outdoors Strong smells (perfumes, cleaning
detergents, etc.)
Rainy days Dry & windy days Cats Dogs Dust Molds Feathers/Birds
What medications have you tried?
_________________________________________________________________________
_________________________________________________________________________________________________________
EVALUATION FOR SINUSITIS:
Do you struggle with frequent sinus infections? Yes No If yes, how many in a given year? _______________
Have you ever had nasal polyps? Yes No Have you lost your sense of smell or taste? Yes No
Have you ever had sinus surgery?
Yes No If yes, list dates: ________________________________________
Please describe in your own words the reason for your visit: ___________________________________________________
_________________________________________________________________________________________________________
_____
____________________________________________________________________________________________________
_________________________________________________________________________________________________________
Patient Name:
3
EVALUATION FOR HEADACHES:
Do you struggle with headaches?
Yes
No
If yes, check the description of the headaches that apply:
Pulsating pain Constant pain Associated with intolerance of loud sounds or bright lights
Worse with physical exertion Duration > 4hrs Debilitating L
ocated only on one side of the head
Located on both sides of the head
EVALUATION FOR HIVES:
When did current bout of hives start? ________________ How often are they occurring? ______________________
How long does each individual hive last?
______________
Are the hives intensely itchy?
Yes No
Do the hives leave dark marks?
Yes No
Have you had any illness before onset of hives?
Yes No
Do you suspect any food triggers?
Yes No
If yes, what foods? ________________________________
Do you take any ibuprofen or ibuprofen-like medications?
Yes No If yes, list: _________________________
Have you noticed hives to be worse with the following? Heat Cold Exercise Scratching S
tress
Showers
Menses
Alcohol
Pressure on the skin
(such as waist band/bra strap areas)
Have you ever had hives before in your lifetime?
Yes
No
Have you had swelling?
Yes No
Have you noticed any of the following?
Throat closing
Shortness of breath
Change in your voice
Tongue swelling
Sensation of something stuck in your throat
OTHER ALLERGIC HISTORY:
Do you have food allergies?
Yes No If yes, list each food or meal and the reaction you had to it:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Have you had any problems after bee or wasp stings?
Yes No If yes, describe the reaction (Do not include
reactions to mosquito bites):
_____________________________________________________________________________
Do you have any drug allergies?
Yes No If yes, list each medication and describe the reaction:
____________________________________________________________________________________________
____________________________________________________________________________________________
Do you have a history of latex allergy? Yes No If yes, describe the reaction: ________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Do you have a history of eczema?
Yes No
Patient Name:
4
MEDICATIONS:
L
ist all medications you currently take (include all over-the-counter medications, eye drops, nasal sprays, inhalers,
birth control pills, digestive aids, vitamins, supplements, aspirins, etc.)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
MEDICAL HISTORY:
P
lease list all chronic medical conditions: Please list all surgeries and hospitalizations with dates:
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
FOR CHILDREN UNDER 15: What was the birth weight? ______________________________________________
Were there any complications before, during or after the delivery?
Yes No If yes, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Has growth and development been normal?
Yes No If no, please explain:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
FAMILY HISTORY:
I
llness/Complaint Father Mother Brother(s) Sister(s)
Son(s)
Daughter(s)
A
sthma
Hay Fever
Food Allergy
Drug Allergy
Eczema
Hives
Headaches
Patient Name:
5
ENVIRONMENTAL SURVEY:
What type of heating/cooling system do you have in your home?
Forced air
Radiator
Baseboard heat
Central air
Window units
Wood burning heat
Fans
Does anyone in your household smoke?
Yes
No If yes, where?
Indoors
Outdoors
Are there any obvious mold problems?
Yes
No Do you use humidifiers?
Yes
No
Is there wall to wall carpeting? Yes No If yes, which rooms? ______________________________________
Do you use feather pillows? Yes No Do you have down comforters or down coats? Yes No
Do you have any family pets? Yes No If yes, please list: _______________________________________
Are there any young children in your home? Yes No If yes, list ages: _______________________________
SOCIAL HISTORY:
Occupation: __________________________________________________________________________________________
How much alcohol do you drink and how often? __________________________________________________________
Do you, or did you ever, smoke? Yes No If yes, how many packs per day on average? ______________
For how many years? _________ If you no longer smoke, when did you quit? _____________________________
Do you exercise regularly? Yes No If yes, what type of exercise? ________________________________
REVIEW OF SYMPTOMS:
General:
Eyes:
Ears:
Nose:
Mouth:
Cardiovascular:
Respiratory:
Gastrointestinal:
GU Female/Male:
Musculoskeletal:
Skin:
Neurological:
Psychological:
Endocrine:
Chills Fatigue Fever Night sweats Weight gain Weight loss None
Dryness Pain Redness Vision changes None
Hearing loss (L,
R, Both) Fullness Ringing None
Bloody nose Discolored discharge Sense of smell Sinus pressure None
Dental problems Sense of taste Thrush Oral ulcers None
Chest pain Palpitations None
Chest tightness Cough Shortness of breath Wheeze None
Abdominal pain Excessive burping Bloating Diarrhea Indigestion
Nausea None
Female: Irregular menses None / Male: Flank Pain Groin Pain None
Leg swelling Muscle aches Numbness Joint pain Tingling
Weakness None
Rash Brittle hair None
Headache Lightheadedness Loss of consciousness None
Anxiety Depression Sleep pattern disturbance None
Hot flashes Excessive sweating None
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Language 1 Female

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Completed 19 April 2021

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