Microsoft word - new patient history and welcome 1_10.doc

Chicago Family Asthma & Allergy, S.C.
Aaron Donnell, M.D. and Kelly Newhall, M.D.
2551 N Clark St, Suite 201, Chicago, IL 60614
773-388-2322, fax 773-388-2333

Thank you for coming to visit us! Here are some details about your first visit at CFAA…
The visit for patient _______________________________________ is on the date of _______________ at time ______________.

Our banner is located above our building entrance on Clark St. There are two entrances marked “2551” at the street level; take the north (left) doorway to access our office. Valet parking is available for $8 Monday-Thursday 9-5 and Friday 9-12. Street parking on Clark is $1 per hour. For the adventurous spirit, side streets may have free spots. Plan to park for up to 2 hours for new patient visits. Arrive 15 minutes prior to your appointment time to check-in. Bring your insurance card and a form of ID. Parents, your driver’s license will do for a child patient’s ID. If your insurance requires a co-pay for your visit, be prepared to pay this at each visit. If your insurance requires a referral for specialist visits (ex. HMO, some POS), please have your doctor fax it to us prior to the visit or bring it with you. Without the referral, you will be responsible for payment of the visit. If you may have allergy skin testing at your visit, you must be off antihistamines for 5 days. It is best to check with us or your doctor before discontinuing any medications that are important to maintain your health. Examples of common antihistamines include: Complete the following patient history and bring it to the appointment to expedite your visit time. 1. Summary of reason for visit: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2. Symptom triggers (circle or complete): Dust Seasons: _______________________________ Food: _________________________________ Other: _________________________________ 3. Medications (include doses or strengths and frequency taken) Current: _________________________________________________________________________________________________ Medications that helped allergies: ____________________________________________________________________________ Medications that did not help: _______________________________________________________________________________ Any side effects: __________________________________________________________________________________________ 4. Ever had allergy tests in the past? (circle) No Yes: Skin or Blood or Other If yes, list results and bring copy to appointment: ________________________________________________________________ 5. Ever had “allergy shots”? Y or N If so, to what and how long? ____________________________________________________ 6. Ever had oral corticosteroids (steroid liquid or pills)? Yes or No If so, how many times and when? ____________________________________________________________________________ 7. Family history: Asthma nasal allergies hay fever eczema food allergy drug allergy cystic fibrosis immune deficiency Mom List any other history of significant medical illness in family: ___________________________________________________________ ____________________________________________________________________________________________________________ 8. Social history (please circle): Home: House Condo Apt New If old, age of home: _________ Recent remodeling: Yes or No Heating: forced air radiator baseboard space heater fireplace ( wood or gas ) Air conditioning: central window none Air filters: central room freestanding HEPA filter Humidifier: No Yes: central freestanding in bedroom Carpet: No Yes: in bedroom not in bedroom Rugs: No Yes: in bedroom not in bedroom Dust control: dust mite coverings: No Yes: pillow mattress Pillow: synthetic feather Comforter: synthetic feather Stuffed animals: No Yes: in bed bedroom not in bedroom Basement: No Yes: damp or dry History of water or flood damage No Yes: fixed not fixed Animals in home: No Yes: cat dog other:_______________ allowed in bedroom not in bedroom Smokers at home: No Yes: patient other outdoors indoors Occupation, or list education level if student: ____________________________________________________________ If patient is child, do they attend preschool or day care? No Yes: days per week: ___________________________ Recent travel outside the United States: No Yes: when and where: ______________________________________ 9. Past medical history (include pertinent dates and reasons): Hospitalizations: __________________________________________________________________________________________ Surgeries: _______________________________________________________________________________________________ Seen by other specialists: ___________________________________________________________________________________ 10. Review of systems (circle “No” or explain if “Yes”): General: any recent fever, weight loss or gain, other: No Yes: ____________________________________________________ Eyes: contacts, glaucoma, cataracts, other: No Yes: ____________________________________________________________ Ears, nose, throat: recurrent ear infections, nasal polyps, enlarged adenoids or tonsils, other: No Yes: __________________ ________________________________________________________________________________________________________ Neurologic: headache, migraines, other: No Yes: ______________________________________________________________ Chest/respiratory: lung disease, other: No Yes: _______________________________________________________________ Cardiovascular: heart disease, chest pain, other: No Yes: ________________________________________________________ Gastrointestinal: reflux, diarrhea, constipation, other: No Yes: ___________________________________________________ Genitourinary: bladder or kidney problems, pregnancy, other: No Yes: _____________________________________________ Endocrine: thyroid disease, diabetes, other hormone disorders: No Yes: ___________________________________________ Immune: recurrent infections, sinusitis, pneumonia, ear infections: No Yes: ________________________________________ ________________________________________________________________________________________________________ Skin: eczema, hives, rashes, other: No Yes: __________________________________________________________________ Psych: anxiety, depression, stress, other: No Yes: _____________________________________________________________ Hematology/oncology: cancer, bleeding disorder, other: No Yes: ________________________________________________

Source: http://www.chicagofamilyasthma.com/files/new_patient_welcome_and_history_form.pdf

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