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):
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: ________________
Kids Health Info FACT SHEET Threadworms Threadworms are any long slender roundworms, commonly found in preschool and school aged children. They often occurin more than one family member. Threadworms look like white threads, about 8mm long. They live in the lower intestine, but come out of the bottom at nightor in the early morning hours to lay their eggs in the area between the buttocks. T
PAIN RELIEF AFTER SURGERY Preparation Quick recovery after surgery can only happen if it doesn’t hurt too much, so effective pain management is one of our main priorities . We expect to be able to keep you very comfortable after your surgery and consequently you should be able to be up and about just a few hours after surgery and you may go home if you wish very soon afterwards. We