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Personal Information
Intake Form

Personal Information

Welcome to EXEMPLAR Allergy and Asthma

 

PATIENT INFORMATION

  • (Please fill out below if patient is a child)

 
 
 

Intake Form

Insurance information

    Primary Insurance Information

  • Secondary Insurance Information

 

Medical History

  • Please fully fill out any section that applies to you (select or fill in the answer)
  • 1. NOSE, EYE, OR SINUS PROBLEMS

  • 2. PULMONARY RESPIRATORY SYMPTOMS

  • 3. ENVIRONMENTAL ALLERGENS AND IRRITANTS

  • 4. ALL PATIENTS please complete this Section

 

5. Complete if your problem includes: URTICARIA (Hives) / ANGIOEDEMA, ECZEMA, or RASH

  • List here medications which you feel are causing your hives/angioedema/rash

 

6. ALL PATIENTS please complete this Section

  • 1. Medications Currently Used: (If you cannot complete the list, bring all bottles/labels to your appointment.)

  • 2. Medication Allergy

  • 3. Food Allergy

  • 4. Latex Allergy/Sensitivity

 

Checklist before Your Allergy/Immunology Appointment

  • 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.
 

Medications Which Interfere with Skin 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.
 

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.
 
 
 
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