Department of Pediatrics io n of Allergy & Immunology Pediatric Allergy and Immunology Location: Faculty Practice Associates 5 East 98th Street, (between 5th and Madison Avenue), 10th floor Phone: 212-241-5548 PRIOR TO YOUR VISIT
Please complete the QUESTIONNAIRE and col ect pertinent medical records and/or test results.
Please have your child stop antihistamine medications (also found in over-the-counter remedies for
al ergy and cold symptoms) as fol ows:
Benadryl, diphenhydramine, chlorpheniramine, brompheniramine – 4 days prior to visit Zyrtec, claritin, allegra, clarinex, hydroxyzine, atarax, rynatan, vistaril – 7 days prior
If you are unsure as to whether a medication is an antihistamine, please check with your pharmacist.
If you cannot discontinue antihistamines or inadvertently took them, we advise that you still KEEP YOUR APPOINTMENT. Do NOT stop antibiotics (such as Amoxicil in, Zithromax), asthma medications (such as Singulair,
Flovent), or steroid nose sprays (such as Flonase, Nasonex). These should be continued.
ON THE DAY OF YOUR VISIT
Please arrive on time or preferably 15 minutes early to complete the registration process.
If you are more than 30 minutes late for your appointment, we cannot guarantee that you wil be
seen due to the large volume of patients.
Parking your car will require extra time. The parking garage is located at 99th Street
between Park and Madison Avenues. Metered parking around Mount Sinai and the vicinity is also
available although limited. Thus, please plan accordingly.
Upon arrival, please have ready upon check-in:
2. Pertinent medical records and test results
4. HMO/PPO authorization/referral form(s) if necessary
5. Name, address and phone number of your referring physician and/or pediatrician.
If you are more than 30 minutes late, you may need to reschedule your appointment.
NOTE: If you must cancel this appointment, please notify us at least 48 hours in advance.
Please be advised that if you cancel your appointment, the next available new-patient appointment
Department of Pediatrics Division of Allergy & Immunology MOUNT SINAI SCHOOL OF MEDICINE PEDIATRIC ALLERGY AND IMMUNOLOGY
Thank you for your time in answering al questions as completely as possible.
We look forward to meeting you and your family.
Date of Birth__________________________
Referring Provider __________________________________________________________
Address of referring provider _____________________________________________________________
Who do you want a report sent to? ________________________________________________________
Reason for visit ____________________________________________________________
Food Allergy History ____None(please skip to next section)
What foods are excluded from your child’s diet?
Which of these foods, if any, are not strictly excluded (e.g. has smal amounts of an ingredient?)
If your child has had an al ergic reaction after eating certain foods, please list:
Has your child been skin tested for food al ergy before? YES NO
Has your child had blood tested for food al ergy before? YES NO ***If YES, please bring test results***
Please list foods avoided purely on the basis of previous testing or advice (there has never been a
Does your child complain of itching in the mouth after eating raw fruits or vegetables?
If yes, please list the fruits or vegetables: ______________________________________________
Eczema/Atopic Dermatitis History ____None (please skip to next section)
What are triggers for eczema flares? ______________________________________________________
How often does your child take a bath/shower? ______________________________________________
How long is the bath/shower? _______________________________________________________
What soap/cleanser do you use? _____________________________________________________
What moisturizer do you use? _______________________________________________________
What medications (topical or oral) have been helpful? _________________________________________
What medications have not been helpful? __________________________________________________
Has the skin ever been infected, requiring oral antibiotics? _____________________________________
Environmental Allergy History ____None (please skip to next section)
Does your child have al ergic symptoms during certain seasons? YES NO
If yes, which season(s) and what type of symptoms?
Does your child have al ergic symptoms after exposure to animals? YES NO
If yes, which animal and what type of symptoms? _______________________________________
Has your child had skin or blood testing for environmental al ergies before? YES NO If yes, please bring test results.
Has your child had a suspected al ergic reaction to insect stings? YES NO
If yes, please specify: _____________________________________________________________
Has your child received al ergy shots before? YES NO
If yes, when and for how long? ______________________________________________________
Asthma/Wheeze/Cough History ____None (please skip to next section) The following questions address symptoms of cough, wheeze, shortness of breath, etc.
Please circle how often these occur: 1. How often does your child
limitation with activity? 6. How many times per year
exacerbations? What medications for asthma/cough/wheeze is your child taking?
How many times has your child needed oral steroids (ie, Orapred, prednisone) for respiratory
symptoms in the past 12 months? ______________________________________________________
Has your child ever been hospitalized for respiratory symptoms? YES NO
If yes, has your child ever been in the intensive care unit (ICU?) YES NO
Drug Allergy History ____None
If your child has had al ergic reactions after taking certain medication, please list:
Current Medications _____None Please list al medications your child is taking (include dose and times): Surgical history (circle if any) _____None
Are your child’s immunizations up to date? YES NO
Have there been any adverse reaction(s) to immunizations? YES NO
If yes, please explain: ____________________________________________________________
**If a member of the family has food al ergies, please specify foods and symptoms: ________________
Is your child’s mattress covered with a special impermeable enclosure? YES NO
If yes, what type of pet(s)?_______________________________________
Does the pet sleep in the child’s room?
Tobacco smoke exposure in family/friend home?
Lastly, what questions/concerns are most important to address?
Reviewed and confirmed by Allergy and Immunology Attending Dr. ________________________________________________
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APPLICATION FOR MEMBERSHIP MEDIMED MEDICAL SCHEME P.O. Box 1672 7 Lutman Road CALL CENTRE 041-395 4474 Port Elizabeth Richmond Hill E-MAIL ADDRESS [email protected] Port Elizabeth www.providence.co.za SECTION 1 PERSONAL DETAILS Please select one option by placing an "X" in the appropriate box SECTION 2 YOUR OPTION Please select one option by p