Your Appointment is on _____________________(date) at _________________________(time). Your Appointment is with: _____Dr. Sally Dee
_____BRIDGEPORT: 153 Main Street, _____MORGANTOWN: 1063 Maple Dr. Suite 1A, Bridgeport WV 26330. Phone: (304) 848-2400 Morgantown, WV 26505. Phone: (304)598-2992 (Mon/Wed/Fri)
(Exit 119 off I79. 50E. Across from Benedum Center )
(Off Route 705; “bubble windows” bldg opposite ACE Hardware) _____FAIRMONT: 100 Avery Olivia Way, Suite B, Fairmont, WV 26554. Phone: (304) 333-1650 (Tue/Thur)
(Pleasant Valley Road; across from Myer’s Business Park)
Checklist before Your Allergy/Immunology Appointment 1. Forms to be Completed and Brought to Appointment. 1. MEDICAL HISTORY FORM
On the Medical History Form, not all questions on the three pages may apply to you. Page 3 applies to everyone, so please fill in all the information on page 3.
2. REGISTRATION FORM (Personal and Insurance Information) 3. (If it applies) Consent Form for Patients less than 18 years-old to be accompanied by someone other
than a parent/guardian. See bottom of the “EXEMPLAR OFFICE PATIENT POLICIES”
2. Stop Antihistamines and medications which would interfere with skin testing, 3 to 5 days before your appointment. See the “MEDICATIONS WHICH INTERFERE WITH SKIN TESTING” list below. Do NOT stop your other medications, including: asthma medication, antibiotics, blood-pressure, and other essential treatments. If uncertain, please call your doctor or call us at the telephone numbers above. Other forms that are attached:
1. General Information for Exemplar Allergy, Asthma, and Immunology
2. Exemplar Office Patient Policies Medications Which Interfere with Skin Testing
Prescription Medications: Antihistamines: Discontinue 3-5 days prior to skin testing. Examples: Astelin, Atarax, Atrohist, Benadryl, Bromfed, Claritin (loratadine), Clarinex, Codimal, Dimetane, Hycomine, Kronofed, Nolahist, Nolamine, Rynatan, Periactin (cyproheptadine), Rynatuss, Semprex, Sinulin, Trinalin or Optimine, Vistaril (hydroxyzine), Xyzal, Astelin, Astepro, Patanase, Patanol, Pataday, Bepreve, Optivar, other antihistamine nasal sprays/eye drops/tablets. Other medications having antihistamine activity which may interfere with skin testing: these medications may need to be discontinued prior to skin testing, but only after discussions with your allergist and your prescribing physician. Examples: Amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), Desipramine (Norpramin), Doxepin (Sinequan), Imipramine (Tofranil), Nortriptyline (Pamelor), Protriiptyline (Vivactil), Trimipramine (Surmontil) Over-the-counter Medications: Cold, flu, sinus, and allergy preparations: Discontinue 3-5 days prior Examples: Actifed, Alka-Seltzer (cold & sinus), Allegra, Allerest, Benadryl (diphenhydramine), Children’s Tylenol (cold & flu), Chlor-Trimeton (chlorpheniramine), Comtrex, Contac, Coricidin, Dimetapp (brompheniramine), Drixoral, Novahistine Elixir, PediaCare (cough & cold), Robitussin (cold), Sine-Off, Sinutab (sinus & allergy), Sudafed (sinus & allergy), Tavist (clemastine), Teldrin, Triaminic, Tylenol (cold, sinus, allergy, flu), Vick’s (cold), Zyrtec (cetirizine) Night-time pain relievers/sleeping aids: Discontinue 3-5 days prior to skin testing Examples: Bayer PM, Doan’s PM, Excedrin PM, Nytol Caplets, Tylenol PM, Unisom Sleep Aid CONTINUE ALL OTHER MEDICATIONS: antibiotics, blood pressure medications, lipid medications, steroids such as prednisone or Medrol dose-pack, nose sprays (except Astelin), etc. We may not be able to skin test you at the first appointment if you have been on systemic steroids (oral or injected prednisone, Medrol, etc.) for 2 or more weeks in the previous month. If you can not be skin tested at the first appointment, you may be skin tested at a subsequent follow-up when you are off antihistamines for 3 to 5 days and off systemic steroids for 2 weeks before testing.
General Information for Patients of Exemplar Allergy, Asthma, and Immunology
We are very pleased that you have selected Exemplar Allergy for your allergy/immunology assessment. This introduction to our clinic is designed to inform you about our background and policies, and familiarize you with some of the tests and treatments we use for allergies and asthma. Our practice is open to patients of all ages. QUALIFICATIONS Both Dr. David W. Goetz and Dr. Sally Dee are certified by the American Board of Allergy and Immunology (of the American Board of Medical Specialties). Dr. Goetz is also board certified in Clinical Laboratory Immunology. ALLERGY CONSULTATIONS We are ready to help you with a wide variety of allergy, asthma, and immunology problems, including: allergic rhinitis (hayfever), asthma, food allergy, immunodeficiencies, bee/wasp/yellow jacket/ant venom allergy, latex allergy, reactions to some medications (e.g. local anesthetics), reactions to immunizations, urticaria (hives) and angioedema, allergic fungal sinusitis, as well as other allergy related problems. YOUR PRIMARY CARE PHYSICIAN AND CONTINUED CARE It is imperative that you have a primary care provider who takes care of your day-to-day medical needs, managing infections, emergency medical conditions, hospitalizations, and providing your routine medical care. We will work closely with your primary care provider in treating your allergic/immunologic or asthmatic problems. However, since we travel among offices in northern West Virginia and will not always be present in your local area, your primary care provider should be your first contact for routine and emergency care. Usually we will see you for an initial consult and possibly one or two follow-up visits. Thereafter, your primary care physician will continue your treatment plan. If you are prescribed allergen vaccine shots, you will be seen in the Allergy Clinic for yearly reevaluations. SKIN TESTING Skin testing is the most sensitive method for identification of the allergenic immunoglobulin, IgE. Exemplar Allergy provides the newest, gentle and rapid methods of prick skin testing. Our standard allergen panel tests for tree, grass, weed, mold, and environmental allergen sensitivity. Skin testing can also be done for foods, latex, Hymenoptera (bee/wasp/vespid/ant) venoms, topical anesthetics, certain drugs, and other allergens. Please be sure that you have stopped taking any antihistamines for 3 to 5 days before your appointment, because these drugs (Claritin, loratadine, Zyrtec, Allegra, Xyzal, Benadryl, Dimetapp, CTM, and others) interfere with skin testing. In addition to not taking antihistamines for 3 to 5 days, we may not be able to skin test you at the first appointment if you have been on systemic steroids (oral or injected prednisone, Medrol, etc.) for 2 or more weeks in the previous month. If you can not be skin tested at the first appointment, you may be skin tested at a subsequent follow-up when you are off antihistamines for 3 to 5 days and off systemic steroids for 2 weeks before testing. SPIROMETRY If asthma is suspected, we will measure your lung function using a spirometer. This is an easy test in which you take a deep breath and blow as hard, and as long, as you can. The test results are important in both the diagnosis and treatment of asthma. TREATMENTS FOR ASTHMA AND ALLERGIES When formulating an allergy or asthma treatment plan for you, we begin with avoidance of identified allergens and irritants. Beyond environmental management and several useful “home remedies”, there are a variety of medical treatments available. Some medications relieve symptoms, while others attack the allergic process itself. Allergen vaccines (allergy shots) may be appropriate for some patients. Our goal is to help you find the best, most effective treatments that relieve your symptoms. ALLERGY SHOTS For some patients, allergen immunotherapy may be prescribed in addition to appropriate oral and nasal medications. Allergy shots are effective treatment for certain selected individuals with allergic rhinitis (seasonal or perennial hayfever) and asthma. Allergen immunotherapy cannot be given at home or to patients on beta-blocker medications. Shots must be given in a medical office with the proper emergency equipment for treating reactions, which may occur after receiving allergy shots. Similar to other immunizations, after receiving an allergy injection there is a 30-minute waiting period before leaving the medical facility. We are available to give allergy shots in each of our offices in Morgantown, Bridgeport, and Fairmont; however, many patients prefer to receive their immunotherapy vaccines (allergy shots) at their primary care provider’s office for convenience. (04/08) EXEMPLAR Allergy and Asthma MEDICAL HISTORY FORM (All patients please complete this 3 page form) Please fully fill out any section that applies to you (circle or fill in the answer)
Name _______________________________________ Age____________ Male / Female Date_________________________
My primary reason for this appointment: nose or eye allergy / sinus problem / asthma / cough / welts or hives / edema or swellings / persisting rash / other reason: ______________________________________________________________________________ Referred by: friend / myself / doctor: ________________________________________________(We’ll send report to this Dr.) 1. NOSE, EYE, OR SINUS PROBLEMS
How Long have you had this problem? _____________________(years/months)
Worst season: all year spring / summer / fall / winter
Known causes: _______________________________________________________
Symptoms BETTER: indoors / outdoors / on vacation / other____________________
Times when symptoms BETTER:_________________________________________
Medications that HELP: _________________________________________________
How many sinus infections a year?_________________________________________
Sinus CAT Scan (date/result):_____________________________________________
ENT surgeon who treated you: ____________________________________________
Allergy testing last done (year)___________where?_______________________________________________________ Treated with allergy shots? From _____to______ Did allergy shots help? Yes / No Stopped because:_______________
2. PULMONARY RESPIRATORY SYMPTOMS
Do you have asthma? Yes / No Who currently manages your asthma? ___________________________________ Hospital admission for asthma? Yes / No (when?)________________________________________________________ Recurrent cough? Yes / No for how long?___________ Wheezing? Yes / No for how long?_______________________ Rescue inhaler (albuterol) use how often? ____times per day, or ____times per week. Wake to use at night? Yes / No Exercise causes?: Short of breath / cough / wheeze Heartburn/acid reflux? Yes / No Reflux at night? Yes / No
3. ENVIRONMENTAL ALLERGENS AND IRRITANTS
Circle any of the following which aggravate your nose/sinus/lung or skin problem: House dust/cleaning
Other animals or allergens ______________________________Chemicals? __________________________________ Other? __________________________________________________________________________________________
4. ALL PATIENTS please complete this Section
Allergic to bee, yellow jacket or wasp sting? (please describe reaction) _________________________________________________ Smoker? Yes / No How many years?______ How many packs per day?__________ Are there other smokers at home? Yes / No Medical conditions (not already listed) briefly:____________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Surgeries you have had in the past (with approximate year): _________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Are your immunizations up to date? Yes / No Immunization allergy? ______________________________________ Do you get a flu shot yearly? Yes / No Had the Pneumovax (pneumonia) shot? Yes / No when last?_____________ Family history: Do parents, brothers, sisters, or your children have the following: (circle) Asthma, Hay fever, Nasal allergy, Sinus, Eczema, Emphysema, Cystic Fibrosis, Lupus, Arthritis, Thyroid Home: Do you live in a: House / Apartment / Mobile Home Home Near: Lake /Woods /Factory /Farm Has your home had any water damage/flooding or excessive mold growth?____________________________________ Humidifier used? Yes / No Home Airconditioned? Yes / No Bed: mattress/waterbed
Home Heating (all that apply): Forced Air / Hot water / Baseboard / Wood stove /Other__________________________ Pests? Ladybugs? Yes / No Cockroaches? Yes / No Other?______________________________________________ Indoor Pets: Cats? #___________Dogs? #__________________ Birds?_________________ Reptiles?_____________ Other pets:_______________________________________________________________________________________ Outdoor Pets/Animals (list type):_____________________________________________________________________ School: Child patient’s current grade in school __________ Adult patient’s current school if any __________________ Patient’s Occupation (adults only)_____________________________ Hobbies________________________________ 5. Complete if your problem includes: URTICARIA (Hives) / ANGIOEDEMA, ECZEMA, or RASH If your problem does NOT include skin problems, please check here ο and CONTINUE ON PAGE 3
My skin problem includes: ____itching, ____hives, ____ swelling? OR _____ eczema/dermatitis/severely itchy skin? How long ago did skin problem begin? __________________. I last had skin problem ___________________________. Continuous? Yes / No. OR Episodic skin problem occurs every _______hrs/days/weeks/months. Where on the body do they occur?___________________________________. They look like?____________________. Do they change location within a day? __________. When gone, do they leave marks in the skin? Yes / No. Things that might cause them? ________________________________________________________________________. Are it/they caused by: ___heat? ___cold? ___pressure? ___tight clothing? ___sun light? ___vibration? ___exercise? ___anxiety? ___latex? ___water? ___food? kind:_____________ medication/vitamin? (list :____________________)
Other?____________________________________________________________________________________________. Associated symptoms? (circle): NONE, asthma, wheezing, throat tightness, nausea/vomiting/diarrhea, fainting/dizzy, nasal polyps, other ____________ Medications which helped control______________________.Medications which did not help them.________________ Number of Emergency room visits?______ Treatment given: ______________________________________________. Other treatments or tests done by other doctors for this problem: _____________________________________________ NSAIDS used (circle): Aspirin, ibuprofen, Motrin, Advil, Naprosyn, Orudis, Relafen, Tolectin, Voltaren, Ponstel, Indocin, Clinoril, Other________ How often do you use an NSAIDS? Daily, every-other-day, weekly, monthly, ___.
List medications which were new for you in the 8 weeks before hives/angioedema/rash began: Medication:_________________________ Started ______days before skin condition began. Still taking? Yes / No. On page 3 you will list medications you are allergic to and what happens if you take the medication. List here medications which you feel are causing your hives/angioedema/rash: Med:__________________ causes:_________________. Med:______________________ causes:_________________. List all illnesses/colds which you had in the 8 weeks before hives/angioedema began: Illness______________________ ;Treatment_______________. Started ______days before hives/etc. Chronic?Yes / No. Illness______________________ ;Treatment_______________. Started ______days before hives/etc. Chronic?Yes / No. Do you or someone in your family have one of the following: Thyroid problems
Asthma, allergies, eczema___ you ___family Other personal or
Hepatitis (liver disease) ___ you ___family
Do you have problems with feeling cold, constipation, unusually fatigued?____________________________ Before rash began did you change soaps, detergents, cosmetics, hair products, cleaning products?: _______________ _____________________________________________________________ Bath/shower Soap brand_________. Do you use fabric softeners? type________________ Dryer sheets? type_____________________________ Changes in job/school?____________________ New pets or hobbies?________________________________________
6. ALL PATIENTS please complete this Section Medication List and Medication / Food / Latex Allergy Questionnaire 1. Medications Currently Used: (If you cannot complete the list, bring all bottles/labels to your appointment.) 2. Medication Allergy If you have NO medication allergies please check here ο and go on to number 3. 1.Medication
3. Food Allergy If you have NO food allergies please check here ο and go on to number 4. List all food you do not tolerate & what reaction occurs if you eat or touch the food.:
____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ ____________________ ______________________________________________________________________________________ 4. Latex Allergy/Sensitivity Latex is the pliable/stretchable material made from the sap of the rubber tree and used in balloons, condoms, elastic bands, padding, and medical materials.
1. Have you ever had a latex reaction or been told you have an allergy or a sensitivity to latex? Yes / No 2. Have you ever had swollen lips or throat after blowing up a balloon or having dental work? Yes / No
Describe if yes:____________________________________________________________
3. Have you ever had a reaction (rash, swelling, itching of hands or eyes, hives, difficulty breathing) after being in contact with
any of the following (circle all that apply):
Erasers containing latex Condoms or diaphragms
4. Do you have a congenital condition, such as spinal bifida, myeloma, or myelodysplasia? Yes / No 5. Had multiple procedures involving the spine or use of multiple catheters before 1-year old? Yes / No 6. Are you allergic to the following foods: (circle) bananas, avocados, kiwi fruit, or chestnuts?
1063 Maple Dr. Suite 1A, Morgantown, WV 26505
100 Avery Olivia Way, Suite B, Fairmont, WV 26554
PATIENT INFORMATION Patient Name (Last, first, middle) ___________________________________________________________ Street_______________________________City_________________________State_________Zip________ Home phone_(AC_______)______________________Email address ________________________________ Date of birth__________________________ Social Security Number_____________________________ Place of employment or school___________________________________Tele # (______)_________________ Primary Care Physician (PCP) _______________________________________________________________ Street___________________________________City_________________________State_________Zip______ PCP telephone #:_(______)___________________________ Pharmacy____________________________City/location__________________ Tele # (______)__________ REFERRED BY_____________________________Heard about Exemplar from:______________ (Please fill out below if patient is a child) Father’s name___________________________________________________Date of birth________________ Place of employment_____________________________________________________________ Work phone_________________________________Social Security Number_______________________ Mother’s name__________________________________________________Date of birth________________ Place of employment________________________________________________________________________ Work phone_________________________________Social Security Number_______________________ INSURANCE INFORMATION Primary insurance company _________________________________________________________________ Address__________________________________________________________________________________ Policy Holder’s Name:__________________________________Policy Holder’s date of birth:_____________ Policy Holder’s Social Security Number:__________________________________ Insured’s (Patient’s) I.D. No._______________________________Group Number____________________ Is this an employers insurance plan?_____________________ Secondary insurance company________________________________________________________________ Address__________________________________________________________________________________ Policy Holder’s Name:__________________________________Policy Holder’s date of birth:_____________ Policy Holder’s Social Security Number:__________________________________ Insured’s (Patient’s) I.D. No._______________________________Group Number____________________ Is this an employers insurance plan?_____________________ PLEASE READ AND SIGN BELOW
I authorize any holder of Medical or other information about me to release to the Social Security Administration and HealthCare Financing Administration or its intermediaries or carriers, or to the billing agent of the physician, any information needed for this or related claim. I permit a copy of this authorization to be used in place of the original; and request payment of medical insurance benefits either to myself or the party who accepts assignment.
Signed_____________________________________________Date_______________ Exemplar Office Patient Policies
Welcome to our office. We are pleased that you have chosen Exemplar for your medical care. In order for us to provide the quality care that you expect in an efficient manner, we must insist that you read and comply with the following policies. 1. We require reasonable notification (24 hours when possible) of cancellation or rescheduling of all
appointments. If three (3) appointments are missed without notification, we will, unfortunately have to terminate our patient relationship.
2. All insurance cards (including Medicaid) need to be available at the time of each appointment. If the
insurance card information is not available for two (2) appointments, you will need to have that visit rescheduled.
3. If you arrive over 15 minutes late for your appointment, the appointment will have to be rescheduled. 4. If you (the patient) are 17 years old or younger, you must be accompanied by a parent or legal gardian. A
Consent Form signed by a parent or legal guardian is required if the under-18y/o patient is accompanied by another adult. This is a legal requirement and no exceptions will be made. (Please fill out the Consent below and sign.)
5. If you do not have insurance and are paying with check or credit/debit card, you need to pay a minimum of half of the charges at the time of each visit. The remainder will be due in 30 days.
6. Exemplar offices operate on a cash-less basis. We accept VISA or MASTERCARD (credit card or debit
card) or check with proper identification.
7. Authorizations (from your insurance company), if necessary, are also your responsibility and are required on
the date of service. Please contact your primary care physician or insurance company with any questions. All co-pays, co-insurance, and deductibles are due in full at your appointment. For questions concerning billing you may contact our billing office: AMBS (Blue Team) at: 800-294-7001 or 304-363-7000.
Consent for Child less than 18 years old to be Seen in the Allergy Clinic If accompanied by someone other than parent/guardian.
I ________________________________, (Parent or legal guardian’s name ) give __________________________________ (Person accompanying minor patient (must be 18yr or older)) permission to have minor child less than 18 years old ______________________________ (Patient’s name) seen and given medical care by Exemplar Inc. (AKA, Exemplar Allergy) providers. _______________________________ _______________________________ Parent or legal Guardian signature Date ______________________________ _______________________________ Witness signature Date
BACKGROUND TO PANDEMIC INFLUENZA Disease Definitions Seasonal Influenza Ordinary seasonal flu occurs every year, usually during the winter. For most people it is an unpleasant but relatively minor illness. As the virus causing ordinary seasonal flu circulates every year, most people build up some immunity to it, although the virus changes slightly every year. A vaccine is available against the cur
U r b a n a n d S u b u r b a n A r e a s S Y S T E M D I M E N S I O N S C H E M I C A L A N D P H Y S I C A L B I O L O G I C A L C O M P O N E N T S H U M A N U S E S Plants and Animals Species Status W h a t I s T h i s I n d i c a t o r , a n d W h y I s Status of "Original Species" I t I m p o r t a n t ? This indicator will report on the degree to which