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:
Stone Oak:
Westover Hills:
T: 210-616-0882
F: 210-692-7833
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
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:
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
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

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