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Allergysa.com

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: ________________

Source: http://www.allergysa.com/img/PatientScreeningForm.docx.pdf

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