1037 19th Ave SW · PO Box 1015 · Willmar, MN 56201
Welcome to the Allergy & Asthma Specialty Clinic. We specialize in the care of adults and children with allergies, asthma, eczema, hives, anaphylaxis and immunodeficiency. During your initial visit, a detailed history and physical examination, pulmonary function test (if you have asthma) and allergy skin tests will be performed. For most allergy-related illnesses, every effort will be made to accomplish these tests in one visit. Please review the following information carefully. Appointment Scheduled For:
Clinic Site: Willmar Office (1037 19th Ave SW)
Hutchinson Medical Center (3 Century Ave)
Marshall Avera Hospital Outreach Area (300 S. Bruce St.)
IMPORTANT: YOU MUST STOP TAKING ALL ANTIHISTAMINE (anti-allergy) MEDICATIONS FOR 7 DAYS PRIOR TO YOUR APPOINTMENT. Taking an antihistamine would interfere with allergy skin testing. If you have any questions about your medication, please call our office and we will be happy to assist you. Some examples of common antihistamines are listed on page 2. BRING THE FOLLOWING TO YOUR APPOINTMENT: Patient History Questionnaire (enclosed). Complete the LEFT SIDE of the form only. Patient Information/Insurance Information Form (enclosed). Patient Insurance Card(s) including prescription plan card. Your medical coverage is
a contract between you and your insurance company. Please verify coverage if you are in a special network or need pre-authorization prior to your appointment. We are not responsible for obtaining prior authorization or a referral (see page 2).
Patient Medical Records. A copy of your previous allergy/asthma related medical
records, especially any allergy testing or lung function testing performed, is needed for review. Contact your previous clinic to obtain these or you can find a records release form on our websiteto submit by mail or fax.
Medications. All prescription and over-the-counter medications you are currently
taking must be listed in the Patient History Questionnaire. Please bring them with to your appointment.
IMPORTANT: YOU MUST STOP TAKING ALL ANTIHISTAMINE (anti-allergy) MEDICATIONS FOR 7 DAYS PRIOR TO YOUR APPOINTMENT. This includes combination antihistamine/decongestants and over-the-counter allergy medications. Please be aware that antihistamines can usually be found in antidepressants, sleep aids and almost always in cough & cold medicines. Some common antihistamines include Allegra (fexofenadine), Atarax (hydroxyzine), Benadryl (diphenhydramine), Claritin (loratadine), Dimetapp, Tylenol PM, Xyzal (levocetirizine) and Zyrtec (cetirizine). You may continue taking nasal sprays (except Astelin and Patanase). If you are taking medications for anxiety, depression or trouble sleeping, please contact our office prior to stopping them.
If you are taking asthma medications such as Advair, Symbicort, Dulera, Pulmicort, Asmanex, QVAR, Flovent, Ventolin, Xopenex, Proventil, albuterol, Maxair, Azmacort, Vanceril, Aerobid, Serevent, Accolate, Singulair or theophylline; it is important you continue taking them. Please bring all of your current medications with to your appointment. Call if you have questions. YOUR APPOINTMENT: Patients under 18 years of age must be accompanied by a parent or guardian. Initial appointments may take 1-2 hours so schedule appropriately and arrive 15 minutes early. As a courtesy to other patients and our office staff, please notify us at least 24 hours in advance if you must cancel or reschedule your appointment. If you have questions or concerns, feel free to contact us toll free at 1-877-866-4824 or visit our website at www.willmarallergy.com. FINANCIAL POLICY: Please understand that payment of your bill is considered a part of your treatment. We urge you to call us prior to your appointment to discuss the approximate cost of treatment. Please be prepared to pay the cost of your visit at the time of service (we accept checks, cash, and Visa and MasterCard). If you have current insurance please bring all insurance cards with you. We will file claims electronically to your insurance carrier; if any claim is disputed by the insurance company, the payment for that claim immediately becomes due. See our complete financial policy at the clinic. REFERRALS: If you are questioning whether your insurance requires a referral, please call the number on the back of your card. Most BlueCross BlueShield policies do not require a referral, except the policy with the state of Minnesota shown on the upper right corner (example shown below).
LOCATION: Our Willmar clinic is located on the south side of 19th Ave SW between Rice Home Medical and Evangelical Free Church. Turn south onto 11th Street and make a quick left into our parking lot. Please call if you need help with directions. We thank you for allowing us to assist you. Please call us if you have any questions about your visit to our office. See you soon!
1037 19th Ave SW · PO Box 1015 · Willmar, MN 56201
IMPORTANT: YOU MUST STOP TAKING ALL ANTIHISTAMINE (anti-allergy) MEDICATIONS FOR 7 DAYS PRIOR TO YOUR APPOINTMENT. PATIENT INFORMATION
Marital Status: Single / Married / Divorced / WidowedIf applicable, provide employer information below: If patient is under 18, provide parent/guardian/responsible party information below: INSURANCE INFORMATION
Please bring your insurance card(s) with to your appointment. We will scan/copy the card for the policy and group numbers to submit to your insurance. Primary Insurance Carrier:
Secondary Insurance Carrier (if applicable):
Name of Policy Holder (if different from above):
I hereby grant authorization to Amy R. Ellingson, MD to release to third party carriers any medical and other information needed about me to determine payment of my bill. I understand that I may revoke this consent at any time. This consent is effective only for this period of confinement. I hereby grant directly to the above named physician the insurance benefits otherwise payable to me but not to exceed the balance due of the physician’s regular charges for the period of treatment. I understand that I am financially responsible to the physician for charges not covered by this authorization.
PATIENT HISTORY QUESTIONNAIRE
Please complete the LEFT SIDE of this form (3 pages)
Check box if you experience these symptoms: PHYSICIAN NOTES
Nasal congestion, plugging, snoring, mouth breathing
Loss of taste or smell Sore throat, voice changes, hoarseness
Coughing, tickle coughs, spells of coughing
Wheezing or shortness of breath Shortness of breath with exercise or coughing
Diagnosis of asthma made years ago Number of past hospitalizations for asthma:
Number of emergency room visits for asthma:
Days missed from school/work in past year?
Possible reaction to food or drug Possible reaction to bee sting
Continuation of allergy shots started years ago
These symptoms occur: (circle all that apply)
Days or weeks at a time or all of the time.
Triggered by exposure to: (circle all that apply) Smoke, dust, animals, mold, odors, perfumes,
aerosols, mowing lawn, barns, raking leaves,
cold air, temperature changes, dampness, menstrual cycle, emotional upset, viral
MEDICATIONS PHYSICIAN NOTES
Please list all current medications including over-the-counter meds.
List the drug name, dosage, how many times a day it is taken, and when it was started.
If more room is needed, please attach a list. Bring meds with to your appointment.
PAST MEDICAL HISTORY
Any history of RSV, infant eczema, or infant reflux/colic?
Immunizations: (circle all that apply) Flu, pneumovax, prevnar, chickenpox, tetanus, other:
FAMILY HISTORY Father:
Other familial diseases (circle all that apply): High blood pressure, diabetes, heart disease, reflux, cancer, arthritis, emphysema, high cholesterol, thyroid disease, cystic fibrosis, other immune deficiency, or skin problems Other:
SOCIAL HISTORY PHYSICIAN NOTES CURRENT ENVIRONMENT/EXPOSURES
Are your pets/animals indoors or outdoors?
Type of bed (mattress, air, crib, etc.) and how old is it?
Do you use dust mite zippered encasings:
Type of bedding (i.e. down comforter, feather pillow)
Any specific exposures at work or school?
Do your symptoms improve when away from home?
REVIEW OF SYSTEMS (check if present)
Fever, chills, night sweats, or significant weight loss/gain
Skin problems (besides eczema or hives)
Throat infections, hoarse voice, or trouble swallowing
Upset stomach, nausea, vomiting, diarrhea or constipation Acid reflux, indigestion or ulcer disease
Hormonal problems (hot flashes) Possible pregnancy or planned pregnancy Other:
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