Joseph D. Diaz, MD Araceli Elizalde, MD Erika Gonzalez, MD
W. Ted Kniker, MD Melissa E. Garcia, PA-C M. Celeste Loera, FNP-BC Revised 6/05/2013 Date: ________________ Patient’s Name: _______________________________________ Age: _________ Patient’s Primary MD: _______________________________________ Practice Type: GP FP Internist Peds Other: _____________________ Who referred you to this clinic? Self-referred Primary MD Other: __________________________________ The patient’s problems are (check all that applies):
Nose symptoms Age when started ______
Persistent Rash or Eczema Age when started ______
Recurring infections Age when started ______Other problems: ______________________________________________________
The patient’s symptoms are present during: I believe the following trigger the patient’s symptoms:
If “Yes” please list who: ______________________________________________________________
If “Yes” please list: ______________________________________________________________
Is the patient exposed to any of the following?
Fireplace Wood-burning stove Strong fumes/chemicals Pollution
Main Office: Southside: Stone Oak: Westover Hills: T: 210-616-0882 F: 210-692-7833 allergysa.com Please indicate the patient’s specific symptoms/Review of Systems (check all that apply):
Redness and irritationYellow mucus in eyes
Throat and Mouth
Coughing up sputum/mucusPain or tightness in chest
Gastrointestinal Muscle and Bone Neurologic Previous Allergy History
Has the patient ever been tested for allergies in the past?
No If “Yes” when? ________________
Has the patient ever been on allergy shots in the past?
No If “Yes” when? ________________
What medicine has the patient been on in the past?
Antihistamines Nasal Steroid Sprays Please List Others: Antihistamine/Decongestant Nasal Antihistamines Medical History Please indicate any past or current medical issues for the patient:
Others (please list): _________________________________________________________________
__________________________________________________________________________________
Please list any surgeries the patient has had and indicate their age at the time:
__________________________________________________________________________________
__________________________________________________________________________________
Please list any significant injuries the patient has had to their head or chest (eg., broken nose, etc):
__________________________________________________________________________________
__________________________________________________________________________________
Family History
Does anyone in the patient’s immediate family have any of the following problems? Nasal allergies Sinus problems Asthma Food allergies Skin allergies Patient’s Mother Patient’s Father Brothers/sisters Patient’s Children Social History
If the patient is a minor, who has custody? _________________________________________________________
Who does the patient live with? _________________________________________________________________
All 3 pages reviewed by provider: __________________________________________ Date: ________________
Joseph D. Diaz, MD