James MacLean, MD Jeanne Gose, MD, PhD Andrew Ober, MD ...

James A MacLean, MD

Patient Information

Patient Name:

Highland Medical & Dental Park 114R Highland Avenue Salem, MA 01970 P: (978) 745-3711 Fax: (978) 745-6208

Danvers Office 140 Commonwealth Ave, Suite 103

Danvers, MA 01923 P: (978) 777-0970 Fax: (978) 762-8589

Jefferson Office Park 820 Turnpike Street, Suite 101

North Andover, MA 01845 P: (978) 683-6256

Fax: (978) 687-0003

Eyal Oren, MD

Cristina Mazzoni Palumbo, MD

Andrew I Ober, MD

Diana Balekian, MD

Date of Birth:

Today's Date:

Occupation:

Referring Physician:

Age:

Sex:

If patient is a child- Mother's Name & Occupation:

Father's Name & Occupation:

Legal Guardian(s):

Address:

Street

City, State

Zip Code

Email:

Home Phone Number:

Cell Phone Number:

What problem brings you or your child to this appointment? What is the main reason for the visit? .

. . . . . .

When did the symptoms begin?:

Are these symptoms getting worse?

Do you have any of the following symptoms? (Check all that apply.)

Cough

Runny nose

Wheezing

Nasal Congestion

Shortness of breath

Itchy Nose

Chest Tightness

Itchy/ Watery Eyes

Sneezing

Postnasal Drip

Other:

Nasal polyps Poor sense of smell Ear infections Sinus infections Blocked ears

Yes

No

Eczema Hives/ Swelling Headaches Snoring Pneumonia

.

Check all of the following which seem to trigger or cause the symptoms, or seem to bother you:

Grass

Cats

Cosmetics

Odors/ smells

Leaves

Dogs

Aerosol sprays

Exercise

Mold & Mildew

Horses

Perfumes

Smoke/ Pollution

Basements

Other animals

Insecticides

Latex

Other:

Alcoholic drinks Cold air Humidity Weather changes

.

When are symptoms the worst?:

All Year

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sept

Oct

Nov

Dec

Are symptoms better away from home? If yes, when?

Yes

No

Have you been skin tested in the past? If yes, what were the results? Yes

No

Have you had allergy injections in the past? If yes, when? Yes

No

Have you received cortisone (prednisone) drugs in the past? If yes, when and how much? Yes

No

Past Medical History: List any hospitalizations/ surgeries:

.

.

Other medical problems: (Check and list all that apply.)

Diabetes

High blood pressure

Heartburn/ reflux

Depression/ anxiety

Have your tonsils/ adenoids been removed? Yes No

Other:

Heart disease

Cancer

Thyroid disease

Autoimmune disease

Have you had ear/ nose/ sinus surgery in the past?

COPD

Yes No

. . . .

Patient Name:

D.O.B.:

. Today's Date:

.

Drug Name

CURRENT MEDICATIONS: (Please include non-allergy meds, vitamins, and alternative/ herbal products.)

Dose

How often taken

Taken for what condition

Allergies Medication allergies:

No known drug allergies

Yes: Please describe what happened and with which medications. .

.

Food allergies or intolerances: None

Yes: Please describe what happened and with which foods.

.

.

Bee sting allergies: None

Yes: Please describe what happened.

.

Family History: (Check off who in your family has had these conditions.)

Condition

Father

Mother

Brother(s)

Sister(s)

Asthma

Eczema

Nasal allergies

(pollens, pets, etc.)

Drug allergies

Food allergies

Bee sting allergy

Son(s)

Adopted: Yes No

Daughter(s)

Other(s)

Who lives with you (the patient)?

.

Environmental Survey (check all that apply):

-Do you live in a (include how House

long have lived there &

# years:

.

approx. how old the home is): Home age:

.

-Do you have:

Humidifier

-Heating system:

Wood/ Coal Stove

-Pets (include # and circle indoor vs. outdoor): -Allergy proof covers: -Type of floor in bedroom: -Air conditioning: -Is your home/ apt humid? -Problems with mice? -Do you smoke currently?

Cats: #

.

indoor or outdoor

Yes

Wall to wall carpet

Yes: Window unit

Yes

Yes

Yes

-Have you smoked in the past?

Yes

When stopped:

Apartment

# years:

.

Home age:

.

Dehumidifier

Radiators/ Forced hot water (Baseboard)

Dogs: #

.

indoor or outdoor

No

Area rug

Yes: Central

No

No

No

#years smoked:

Duplex

# years:

.

Home age:

.

Air cleaner

Forced hot air

Birds: #

.

indoor or outdoor

-Type of mattress:

Wood

No

-Water leaks/ mold:

-Problems with roaches?

-Any tobacco smokers in the home?

.

Condo/Townhouse

# years:

.

Home age:

.

HEPA filter

Electric

Mixed

Other:

indoor or outdoor

Spring

. Foam

Yes

No

Yes

No

Yes

No

No

ASTHMA PATIENTS ONLY: (Please check off the box next to the most applicable answer.) 1. In the past 4 weeks, how often did your asthma keep you from getting as much done at work, school, or home?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

2. During the past 4 weeks, how often have you had shortness of breath?

More than once a day

Once a day

3-6 times a week

Once or twice a week Not at all

3. During the past 4 weeks, how often did your asthma symptoms (cough, wheeze, shortness of breath, chest tightness, etc.) wake you up at night or earlier than usual in the morning?

4 or more nights a week

2-3 nights a week

Once a week

Once or twice

Not at all

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

3 or more times a day

1-2 times a day

2-3 times per week

Once a week or less

Not at all

5. How would you rate your asthma control during the past 4 weeks?

Not controlled at all

Poorly controlled

Somewhat controlled Well controlled

Completely controlled

1

2

3

4

5

Total Score:

/25

Patient Name:

D.O.B.:

. Today's Date:

.

Do you experience any of the following symptoms? Check all that apply.

System:

Symptoms:

Yes

No

Recurrent fevers

Fatigue

General:

Weight loss

Weight gain

Other:

Blurred vision

Eyes:

Pain in eyes Light flashes

Other:

Hearing difficulty

Ears/ Nose:

Nose bleeds Ear popping

Other:

Mouth sores

Mouth/ Throat: Hoarseness

Other:

Swelling

Neck

Masses

Other:

Fluttering heart

Rapid/ unusual heartbeat

Chest Pain Cardiovascular:

Swollen ankles

High blood pressure

Other:

Cough

Wheeze

Respiratory: Shortness of breath

Poor exercise tolerance

Other:

System: Gastrointestinal: Genitourinary:

Endocrine: Bones/ Joints:

Skin: Psychological:

Symptoms: Heartburn Stomach pains Vomitting Diarrhea Other: Pain on urination Up at night to urinate Kidney stones Other: Excessive sweating Constant thirst Feel too warm Feel too cold Other: Painful joints Swollen joints Muscle pain Other: Rashes Itching Other: Depression Anxiety Other:

Yes

No

What is your pain level on a scale from 0 (no pain) to 10 (worst pain)?

(i.e. pain caused by your allergic condition)

.

-STOP HERE-

Questionnaire reviewed by:

Date:

.

Patient Name:

D.O.B.:

. Today's Date:

.

TESTS ORDERED (circle):

Environmental:

6-panel

Foods:

Eczema Panel Grains Peanut

For the Physician to complete:

Pedi (3)

Tree Nut (1) Panel MME Panel Egg

Pedi IT (4)

Nuts&Seeds (all) Adult Foods (1) Milk

Intradermals

Shellfish Fruits & Veggies Wheat

Finned Fish Soy

Baked Muffins: Fresh Butters:

Baked Milk (no egg)

Peanut Soybutter

Baked Egg (no milk)

Almond Sunbutter

Baked Milk (with egg) Baked Egg (with milk)

Cashew Other:

Walnut

Nutella

Antibiotics: Special Tests: Local Anesthetics:

Corticosteroids: Patch Testing: Respiratory:

Penicillin Venom Xylocaine (lidocaine) Triamcinolone NA- 80 PFT (Pre)

Cefazolin Latex Marcaine (bupivacaine) Depomedrol Metals PFT (Pre) & Post

Ceftriaxone Ice Cube Carbocaine (mepivacaine) Solumedrol NA- 80 + Metals (10) PFT + Insp loop

Azithro Other: Sensorcaine

Dexamethasone Custom Series Pulse Ox

EDUCATION (circle): Food avoidance Epipen

DM control

Pet avoidance

FAAN MDI

OAS MDI w/ spacer

Immunotherapy MDI w/ spacer & mask

Nasal sprays Peak flow meter

IMPRESSION/ NOTES:

Physician: Pt. to return to office in:

. . . . . . . . . . . . . .

Date:

.

days/ weeks/ months/ year

for

follow up/ skin testing/ patch test

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download