_____ _

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 Corporate Hill Drive - Uttle Rock Arkansas 72205 - (501)224-1156 - FAX (501)223-2625 wwwlittlerockallergycom

PRE-REGISTRATION NEW PATIENT

PATIENT

o Dr 0 Miss 0 Ms 0 Mrs 0 Mr Patient Name---_____--____~---_______~---(First) (Middle) (last) nickname If any

o Female 0 Male Date of Birth______---Age____

Race 0 American Indian or Alaska Native 0 Asian 0 Black or African American

o Native Hawaiian or Other Pacific Islander 0 White 0 Patient Declined

Ethnicity 0 Hispanic or Latino 0 Not Hispanic or Latino 0 Patient Declined

o Married 0 Single 0 Divorced 0 Widower Social Security Number of Patient _________

Address____________________~Apt__Lot__

City______________State___Zip____

Email_____________Home Phone Work Phone_______

Patients EmployerSchool ___________________Occupation_______

Name of Spouse Date of Birth Social Security Number _______

Spouses Employer Occupation Work Phone_____

If patient is a minor Parents 0 Married 0 Single 0 Divorced 0 Widower

Fathers Name Social Security Date of Birth____

Address CityStateZip Home Phone______

Fathers Employer Occupation Work Phone____

Mothers Name Social Security Date of Birth____

Address CityStateZip Home Phone______

Mothers Employer Occupation__________ Work Phone

Patient lives with MOTHER or FATHER or BOTH (Please circle one)

Patients Primary Physician ____---__----________CityState__________ (if none type none)

Referring Physician if different__---___--________CityState_________ (It none type none)

Who referred you if different_______________CityState__________

Family Members who are patients at Uttle Rock Allergy amp Asthma Clinic______________

Type of allergy symptoms Hay FeverSinus__Asthma__Hives__Other (please explain) _______

Your appointment (datetime) ____________________________

with Dr Gene L France Dr Jim M Ingram I Dr Karl V Sitz Dr Blake G Scheer I Dr Stacy Griffin

The undersigned consents to laboratory tests of hisher blood for the hepatitis virus and the human immunodeficiency virus (HIV) if an employee has a potential exposure through contact with the patient

Signature of Patient or Legal Guardian__________________Date______

LITTLE ROCK ALLERGY amp ASTHMA CLINIC PA 18 Corporate Hill Drive - Little Rock Arkansas 72205 - (501)224-1156 - FAX (501)223-2625

wwwlittlerockallergycom GUARANTOR AND INSURANCE INFORMATION

PRIMARY INSURANCE INFORMATION Insurance COmpany____________--------Phone_________

IF NONE WRrTC NONE

Address__________________ CityjStatejZip____________

Subscriber Name____________________ Date of Blrth_______

Social Security Number Insurance effective date__________

Relationship to Patient____________

Policy ID Number______________ Group Number ____________

SECONDARY INSURANCE INFORMATION Insurance COmpany______=~==--_---____ Phone_________

IF NONE WRrTC NONE

Address___________________ CityStateZlp__________

Subscriber Name Date of Blrth_______

Social Security Number Insurance effective date__________

Relationship to Patient____________

Policy ID Number______________ Group Number ____________

GUARANTOR OR RESPONSIBLE PARTY Name---_____~______________ Date of Birth__________

Social Security _______________

Address___________________ CityStateZip________

Home Phone_______ Work Phone______

Patients Name (if not the same)______________

ACKNOWLEDGMENT AND AUTHORIZATION

I understand that as the guarantor (patient) I am finanCially responsible for any balance not covered under the terms and conditions of my health insurance coverage

I authorize my insurance benefits paid directly to Little Rock Allergy and Asthma Clinic PA 18 Corporate Hill Uttle Rock Arkansas 72205

I understand if I am unable to keep my scheduled appointment I am asked to give at least 24 hours notice or possibly be required to pay a fee

I authorize Little Rock Allergy and Asthma Clinic PA to release any medical or other Information to my insurance company when requested

Signature Date

Printed Name Relationship to patient Guarantor 2014

AGE____NAME____________

ID (For Office Use Only)_____Date of Appointment______

NeVI Patient History

Person Completing the form Patient Referred by Family Doctor

Mother Friend

Father Family member

r Grandparent Self

I Guardian I Another LRAA patient

Health aide other physician

Nurse r Oter I Other

What are your main concerns today

I congestion sneezing I headache Other

I runny nose cough I earache I post-nasal drip exercise problems recurrent infections I nasal itch wheezing food allergy

I eye itch I chest pain I eczema

r- throat clearing r- shortness of breath r- hives~ tearing eyes - asthma rashI I sniffing I stinging insect reactions

~ - sinus pain latex allergy

sore throat r- vomiting

Medication Reaction

Lung function tests are adjusted based on race for accuracy Please indicate which item best describes you (the patient)

~ AfrlcanAmerican ( Native American ( Asian C Caucasian ( Hispanic

Family Doctor

r Other

I

Medication Name StrengthDose How Many

(pills inhalers sprays creams shots)

1

I

How Many Times

a Day

- -shy

I

I

~ i

I

I ~ ~

~ 1

I ~

I rshy

I (~Runny nose Major problem Less of a Problem Not aProblem

-- shyStuffy noseCongestion Major problem Less of aProblem Not a Problembull - shy ( shy I Sneezing Major problem Less of aProblem Not a Problemi shy~ Nasal ttch Major problem Less of aProblem Not aProblem (- shyi r-Post nasal driplthroat clearing Major problem Less of a Problem Not a Problem

I

( shy

(- a (Hoarseness Major problem Less of a Problem Not aProblem

Discolored drainage (Major problem Less of a Problem Not aProblem- i - Facial pressure (-

Major problem Less of a Problem Not a ProblemI ( shy

1 Major problem Less of aProblem (

Not a ProblemSore throat J

shy1 Major problem Less of a Problem Not a Problem4 Headaches ( (-

i to (-Snoring -- Major problem Less of a Problem Not aProblem j (- ( J Loss of sense of smell Major problem Less of a Problem ( Not aProblem

- r- r Nosebleeds Major problem Less of a Problem Not a Problem ( a (-I Recurring sinus infections Major problem Less of a Problem Not a Problem 1

(- r- Sniffing Major problem

(-

Less of aProblem Not aProblemJ 1 - (j Sinus Pain (Major problem Less of a Problem Not aProblem

- ( ( shyI Major problem Less of a Problem Not a Problem

1

Ears

(- (- (-1

Recurring ear infections Major Problem Less of a Problem Not a Problem1

I ttchyears ( ( (Major Problem Less of aProblem Not a Problem

(- (-Ringing in ears IAajor Problem Less of a Problem Not a Problem (- -1 PoppingStuffy Major Problem Less of aProblem ( Not a Problem

I (- - (Hearing loss Not a Problem

I Major Problem Less of a Problem ( (- (-Balance problems Major Problem Less of a Problem Not a Problem

I ~

1j

1 I 1

AI[ergy 1~ (

(- (~

Are you having (allergy) eye ear nose or throat problems Yes No

If the above answer is NO please go to Page 4 (4th tab)

How manyears have you had symptoms Symptom frequency1 less than 1 1 daily

11-5 IlIeel1y

6-10 1 month~

111-20 r seasonal~

1 over 20 1 rarely

1 none

Please mark the items which best describe your symptoms

Eyes r 1-

~chy Major Problem Less of aProblem Not aProblem (

( (Watery Major Problem Less of aProblem Not aProblem ( (

Red t Itlajor Problem Less of aProblem Not aProblem

Puffy or Dark circles under eyes Major Problem Less of aProblem ( Not aProblem - I t Pain Major Problem Less of aProblem Not aProblem (-

Vision Change Major Problem Less of aProblem Not aProblem

Please indicate if you have had any of the following treatments

If you did have the treatment please indicate if it was helpful or not ( ( roO

Antihistamines (Cia rrrin Zyrtec Allegra etc) No Yes -Helpful Yes -Not Helpful -

I Decongestants (Tylenol Sinus Sudafed etc) No Yes -Helpful Yes -Not Helpful --

Steroid nasal sprays (Flonase Rhinocort Nasonex etc) No ( Yes -Helpful Yes -Not Helpful ( (-Singulair No Yes -Helpful Yes -Not Helpful ( (

Non-prescription nasal sprays (Afrin Neosynephrine etc) No Yes -Helpful Yes -Not Helpful ( -

iAntihistarnine nasal spray (AsteproAstenn Patanase) No Yes -Helpful Yes -Not Helpful ( (

Allergy eye drops (Pataday Bepreve Optivar Patanol etc) No Yes -Helpful Yes -Not Helpful

(- J- IAllergy shots No r- Yes -Helpful Yes -Not Helpful

(- ( IIf you had allergy shots are you still on shots No Yes - Helpful - Yes -Not Helpful

Has Patient Had ( (Asinus CT scan in the past year Yes No ( An evaluation by an Ear Nose and Throat Specialist Yes No

[Sinus surgery ( Yes No

~ f rAdenoids removed Yes Noi I (rTonsils removed Yes No 1 -

r Ii Nasal po~ps Yes No J 1 (Tubes placed in ears Yes ( 110 I (- roO

I Allergy testing Yes No

1 I skin test j r blood work test 1

1 l

II

Nasal andor breathing Symptoms are 1 Weather changes 1 exercise 1 odorsfumes tnggered by 1 Hot hum~ days r infect~ns r aspirin

1 household dust 1 musty rooms rpets 1 outdoor activtties r smoke 1 cold air

What are the Ylorst seasons 1 year round 1 spring 1 slimmer - fall

1 winter fODdAllergy

Have food allergies been aproblem (Yes No

Food allergy symloms rhiveswefts Problem foods include 1 m~k 1mouthfthroat nch [ wheat 1 anaphylactic shock r ffAh 1sneezing [soy 1 cough [ peanut 1 diarrhea 1 shellffAh I~ wheezing [ egg

1 vomHing 1tree nut 1 eczema 1 other

Eczem~

Has eczema been aproblem Yes ( No

Eczema triggers 1 weather changes How long has eczema been 1 0-6 months Frequency of 1 dai~

1 food aproblem 1712 months symptoms r weekrr 1 seasons 1 1-5 years r~ month~ 1 soapshampoo r6-15 years r yearrr 1 clothing lover 15 years roccasionalrr 1other r none 1 none

Hives i Have hives been a problem rYes r No

Hives began I recently Hives are associated with r lip swelling r- wfthin the past few months I joint swelling r in the past year r bruising r- years ago I eyelid swelling

Hives appear to be triggered by I eating certain foods Hives occur r daily Hives last for r under 24 hours

I pain relievers r weekly r 1-3 days I exercise r monthly 11--4 weeks I other medication I rarely lover 4 weeks I infections I occasionally I cold I none I not sure

Stinging insect reactions - - I

Have stinging insect reactions been a problem ( Yes

Stings causing reactions I ants Reactions I swelling around the sting sfte only I bees I hiveswefts I hornets I trouble breathing

I wasps I passing out I yeHow jaCKets I other

Do you have epinephrine (Epi-Pen etc) ( No

Have you ever been treated in the ER for asting reaction (- Yes ( No

Have youever had any of the following (Past Medical History)

I No known Problem

r migraine headaches heart disease glaucoma high blood pressure osteoporosis I diabetes r epilepsyseizures I fibromyalgia I hepatitis I hiatal herniareflux depression r HIVAIOS r- bipolar disorder I ADDADHO I arthritis I thyroid disease I pneumonia I cataracts r- Kidney disease I positiveTB

anemia

COPO I ulcers

v

Infections Current Problems

Cancer

Other

Other

other

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

I

~ i

I

I ~ ~

~ 1

I ~

I rshy

I (~Runny nose Major problem Less of a Problem Not aProblem

-- shyStuffy noseCongestion Major problem Less of aProblem Not a Problembull - shy ( shy I Sneezing Major problem Less of aProblem Not a Problemi shy~ Nasal ttch Major problem Less of aProblem Not aProblem (- shyi r-Post nasal driplthroat clearing Major problem Less of a Problem Not a Problem

I

( shy

(- a (Hoarseness Major problem Less of a Problem Not aProblem

Discolored drainage (Major problem Less of a Problem Not aProblem- i - Facial pressure (-

Major problem Less of a Problem Not a ProblemI ( shy

1 Major problem Less of aProblem (

Not a ProblemSore throat J

shy1 Major problem Less of a Problem Not a Problem4 Headaches ( (-

i to (-Snoring -- Major problem Less of a Problem Not aProblem j (- ( J Loss of sense of smell Major problem Less of a Problem ( Not aProblem

- r- r Nosebleeds Major problem Less of a Problem Not a Problem ( a (-I Recurring sinus infections Major problem Less of a Problem Not a Problem 1

(- r- Sniffing Major problem

(-

Less of aProblem Not aProblemJ 1 - (j Sinus Pain (Major problem Less of a Problem Not aProblem

- ( ( shyI Major problem Less of a Problem Not a Problem

1

Ears

(- (- (-1

Recurring ear infections Major Problem Less of a Problem Not a Problem1

I ttchyears ( ( (Major Problem Less of aProblem Not a Problem

(- (-Ringing in ears IAajor Problem Less of a Problem Not a Problem (- -1 PoppingStuffy Major Problem Less of aProblem ( Not a Problem

I (- - (Hearing loss Not a Problem

I Major Problem Less of a Problem ( (- (-Balance problems Major Problem Less of a Problem Not a Problem

I ~

1j

1 I 1

AI[ergy 1~ (

(- (~

Are you having (allergy) eye ear nose or throat problems Yes No

If the above answer is NO please go to Page 4 (4th tab)

How manyears have you had symptoms Symptom frequency1 less than 1 1 daily

11-5 IlIeel1y

6-10 1 month~

111-20 r seasonal~

1 over 20 1 rarely

1 none

Please mark the items which best describe your symptoms

Eyes r 1-

~chy Major Problem Less of aProblem Not aProblem (

( (Watery Major Problem Less of aProblem Not aProblem ( (

Red t Itlajor Problem Less of aProblem Not aProblem

Puffy or Dark circles under eyes Major Problem Less of aProblem ( Not aProblem - I t Pain Major Problem Less of aProblem Not aProblem (-

Vision Change Major Problem Less of aProblem Not aProblem

Please indicate if you have had any of the following treatments

If you did have the treatment please indicate if it was helpful or not ( ( roO

Antihistamines (Cia rrrin Zyrtec Allegra etc) No Yes -Helpful Yes -Not Helpful -

I Decongestants (Tylenol Sinus Sudafed etc) No Yes -Helpful Yes -Not Helpful --

Steroid nasal sprays (Flonase Rhinocort Nasonex etc) No ( Yes -Helpful Yes -Not Helpful ( (-Singulair No Yes -Helpful Yes -Not Helpful ( (

Non-prescription nasal sprays (Afrin Neosynephrine etc) No Yes -Helpful Yes -Not Helpful ( -

iAntihistarnine nasal spray (AsteproAstenn Patanase) No Yes -Helpful Yes -Not Helpful ( (

Allergy eye drops (Pataday Bepreve Optivar Patanol etc) No Yes -Helpful Yes -Not Helpful

(- J- IAllergy shots No r- Yes -Helpful Yes -Not Helpful

(- ( IIf you had allergy shots are you still on shots No Yes - Helpful - Yes -Not Helpful

Has Patient Had ( (Asinus CT scan in the past year Yes No ( An evaluation by an Ear Nose and Throat Specialist Yes No

[Sinus surgery ( Yes No

~ f rAdenoids removed Yes Noi I (rTonsils removed Yes No 1 -

r Ii Nasal po~ps Yes No J 1 (Tubes placed in ears Yes ( 110 I (- roO

I Allergy testing Yes No

1 I skin test j r blood work test 1

1 l

II

Nasal andor breathing Symptoms are 1 Weather changes 1 exercise 1 odorsfumes tnggered by 1 Hot hum~ days r infect~ns r aspirin

1 household dust 1 musty rooms rpets 1 outdoor activtties r smoke 1 cold air

What are the Ylorst seasons 1 year round 1 spring 1 slimmer - fall

1 winter fODdAllergy

Have food allergies been aproblem (Yes No

Food allergy symloms rhiveswefts Problem foods include 1 m~k 1mouthfthroat nch [ wheat 1 anaphylactic shock r ffAh 1sneezing [soy 1 cough [ peanut 1 diarrhea 1 shellffAh I~ wheezing [ egg

1 vomHing 1tree nut 1 eczema 1 other

Eczem~

Has eczema been aproblem Yes ( No

Eczema triggers 1 weather changes How long has eczema been 1 0-6 months Frequency of 1 dai~

1 food aproblem 1712 months symptoms r weekrr 1 seasons 1 1-5 years r~ month~ 1 soapshampoo r6-15 years r yearrr 1 clothing lover 15 years roccasionalrr 1other r none 1 none

Hives i Have hives been a problem rYes r No

Hives began I recently Hives are associated with r lip swelling r- wfthin the past few months I joint swelling r in the past year r bruising r- years ago I eyelid swelling

Hives appear to be triggered by I eating certain foods Hives occur r daily Hives last for r under 24 hours

I pain relievers r weekly r 1-3 days I exercise r monthly 11--4 weeks I other medication I rarely lover 4 weeks I infections I occasionally I cold I none I not sure

Stinging insect reactions - - I

Have stinging insect reactions been a problem ( Yes

Stings causing reactions I ants Reactions I swelling around the sting sfte only I bees I hiveswefts I hornets I trouble breathing

I wasps I passing out I yeHow jaCKets I other

Do you have epinephrine (Epi-Pen etc) ( No

Have you ever been treated in the ER for asting reaction (- Yes ( No

Have youever had any of the following (Past Medical History)

I No known Problem

r migraine headaches heart disease glaucoma high blood pressure osteoporosis I diabetes r epilepsyseizures I fibromyalgia I hepatitis I hiatal herniareflux depression r HIVAIOS r- bipolar disorder I ADDADHO I arthritis I thyroid disease I pneumonia I cataracts r- Kidney disease I positiveTB

anemia

COPO I ulcers

v

Infections Current Problems

Cancer

Other

Other

other

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Eyes r 1-

~chy Major Problem Less of aProblem Not aProblem (

( (Watery Major Problem Less of aProblem Not aProblem ( (

Red t Itlajor Problem Less of aProblem Not aProblem

Puffy or Dark circles under eyes Major Problem Less of aProblem ( Not aProblem - I t Pain Major Problem Less of aProblem Not aProblem (-

Vision Change Major Problem Less of aProblem Not aProblem

Please indicate if you have had any of the following treatments

If you did have the treatment please indicate if it was helpful or not ( ( roO

Antihistamines (Cia rrrin Zyrtec Allegra etc) No Yes -Helpful Yes -Not Helpful -

I Decongestants (Tylenol Sinus Sudafed etc) No Yes -Helpful Yes -Not Helpful --

Steroid nasal sprays (Flonase Rhinocort Nasonex etc) No ( Yes -Helpful Yes -Not Helpful ( (-Singulair No Yes -Helpful Yes -Not Helpful ( (

Non-prescription nasal sprays (Afrin Neosynephrine etc) No Yes -Helpful Yes -Not Helpful ( -

iAntihistarnine nasal spray (AsteproAstenn Patanase) No Yes -Helpful Yes -Not Helpful ( (

Allergy eye drops (Pataday Bepreve Optivar Patanol etc) No Yes -Helpful Yes -Not Helpful

(- J- IAllergy shots No r- Yes -Helpful Yes -Not Helpful

(- ( IIf you had allergy shots are you still on shots No Yes - Helpful - Yes -Not Helpful

Has Patient Had ( (Asinus CT scan in the past year Yes No ( An evaluation by an Ear Nose and Throat Specialist Yes No

[Sinus surgery ( Yes No

~ f rAdenoids removed Yes Noi I (rTonsils removed Yes No 1 -

r Ii Nasal po~ps Yes No J 1 (Tubes placed in ears Yes ( 110 I (- roO

I Allergy testing Yes No

1 I skin test j r blood work test 1

1 l

II

Nasal andor breathing Symptoms are 1 Weather changes 1 exercise 1 odorsfumes tnggered by 1 Hot hum~ days r infect~ns r aspirin

1 household dust 1 musty rooms rpets 1 outdoor activtties r smoke 1 cold air

What are the Ylorst seasons 1 year round 1 spring 1 slimmer - fall

1 winter fODdAllergy

Have food allergies been aproblem (Yes No

Food allergy symloms rhiveswefts Problem foods include 1 m~k 1mouthfthroat nch [ wheat 1 anaphylactic shock r ffAh 1sneezing [soy 1 cough [ peanut 1 diarrhea 1 shellffAh I~ wheezing [ egg

1 vomHing 1tree nut 1 eczema 1 other

Eczem~

Has eczema been aproblem Yes ( No

Eczema triggers 1 weather changes How long has eczema been 1 0-6 months Frequency of 1 dai~

1 food aproblem 1712 months symptoms r weekrr 1 seasons 1 1-5 years r~ month~ 1 soapshampoo r6-15 years r yearrr 1 clothing lover 15 years roccasionalrr 1other r none 1 none

Hives i Have hives been a problem rYes r No

Hives began I recently Hives are associated with r lip swelling r- wfthin the past few months I joint swelling r in the past year r bruising r- years ago I eyelid swelling

Hives appear to be triggered by I eating certain foods Hives occur r daily Hives last for r under 24 hours

I pain relievers r weekly r 1-3 days I exercise r monthly 11--4 weeks I other medication I rarely lover 4 weeks I infections I occasionally I cold I none I not sure

Stinging insect reactions - - I

Have stinging insect reactions been a problem ( Yes

Stings causing reactions I ants Reactions I swelling around the sting sfte only I bees I hiveswefts I hornets I trouble breathing

I wasps I passing out I yeHow jaCKets I other

Do you have epinephrine (Epi-Pen etc) ( No

Have you ever been treated in the ER for asting reaction (- Yes ( No

Have youever had any of the following (Past Medical History)

I No known Problem

r migraine headaches heart disease glaucoma high blood pressure osteoporosis I diabetes r epilepsyseizures I fibromyalgia I hepatitis I hiatal herniareflux depression r HIVAIOS r- bipolar disorder I ADDADHO I arthritis I thyroid disease I pneumonia I cataracts r- Kidney disease I positiveTB

anemia

COPO I ulcers

v

Infections Current Problems

Cancer

Other

Other

other

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Nasal andor breathing Symptoms are 1 Weather changes 1 exercise 1 odorsfumes tnggered by 1 Hot hum~ days r infect~ns r aspirin

1 household dust 1 musty rooms rpets 1 outdoor activtties r smoke 1 cold air

What are the Ylorst seasons 1 year round 1 spring 1 slimmer - fall

1 winter fODdAllergy

Have food allergies been aproblem (Yes No

Food allergy symloms rhiveswefts Problem foods include 1 m~k 1mouthfthroat nch [ wheat 1 anaphylactic shock r ffAh 1sneezing [soy 1 cough [ peanut 1 diarrhea 1 shellffAh I~ wheezing [ egg

1 vomHing 1tree nut 1 eczema 1 other

Eczem~

Has eczema been aproblem Yes ( No

Eczema triggers 1 weather changes How long has eczema been 1 0-6 months Frequency of 1 dai~

1 food aproblem 1712 months symptoms r weekrr 1 seasons 1 1-5 years r~ month~ 1 soapshampoo r6-15 years r yearrr 1 clothing lover 15 years roccasionalrr 1other r none 1 none

Hives i Have hives been a problem rYes r No

Hives began I recently Hives are associated with r lip swelling r- wfthin the past few months I joint swelling r in the past year r bruising r- years ago I eyelid swelling

Hives appear to be triggered by I eating certain foods Hives occur r daily Hives last for r under 24 hours

I pain relievers r weekly r 1-3 days I exercise r monthly 11--4 weeks I other medication I rarely lover 4 weeks I infections I occasionally I cold I none I not sure

Stinging insect reactions - - I

Have stinging insect reactions been a problem ( Yes

Stings causing reactions I ants Reactions I swelling around the sting sfte only I bees I hiveswefts I hornets I trouble breathing

I wasps I passing out I yeHow jaCKets I other

Do you have epinephrine (Epi-Pen etc) ( No

Have you ever been treated in the ER for asting reaction (- Yes ( No

Have youever had any of the following (Past Medical History)

I No known Problem

r migraine headaches heart disease glaucoma high blood pressure osteoporosis I diabetes r epilepsyseizures I fibromyalgia I hepatitis I hiatal herniareflux depression r HIVAIOS r- bipolar disorder I ADDADHO I arthritis I thyroid disease I pneumonia I cataracts r- Kidney disease I positiveTB

anemia

COPO I ulcers

v

Infections Current Problems

Cancer

Other

Other

other

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Hives i Have hives been a problem rYes r No

Hives began I recently Hives are associated with r lip swelling r- wfthin the past few months I joint swelling r in the past year r bruising r- years ago I eyelid swelling

Hives appear to be triggered by I eating certain foods Hives occur r daily Hives last for r under 24 hours

I pain relievers r weekly r 1-3 days I exercise r monthly 11--4 weeks I other medication I rarely lover 4 weeks I infections I occasionally I cold I none I not sure

Stinging insect reactions - - I

Have stinging insect reactions been a problem ( Yes

Stings causing reactions I ants Reactions I swelling around the sting sfte only I bees I hiveswefts I hornets I trouble breathing

I wasps I passing out I yeHow jaCKets I other

Do you have epinephrine (Epi-Pen etc) ( No

Have you ever been treated in the ER for asting reaction (- Yes ( No

Have youever had any of the following (Past Medical History)

I No known Problem

r migraine headaches heart disease glaucoma high blood pressure osteoporosis I diabetes r epilepsyseizures I fibromyalgia I hepatitis I hiatal herniareflux depression r HIVAIOS r- bipolar disorder I ADDADHO I arthritis I thyroid disease I pneumonia I cataracts r- Kidney disease I positiveTB

anemia

COPO I ulcers

v

Infections Current Problems

Cancer

Other

Other

other

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

BirthHistory-AOULTSSKIPTOIMMUlUZATlON( _ ~

Problems during pregnancy

Yes ( No

Prematureor term (weeks) 1 under 26 12amp30 131-36 1 over 37

Lung disease ( Yes r- No

required ventilation Yes

No

required oxygen ( Yes No

Breast fed shy less than 4months

4months or more

Formula used ( Milk-based soy

other

Immunizations - -

Routine childhood immunizations are up to date r- Yes (- No

(-Idon~ know

Recered Pneumovax (Pneumonia vaccine) t Yes r- No r Idont fmo

month I year

Tetanus in last ten years t- Yes - No -

Idon~ know

Flu shot in the past year ( Yes (- No

month I year

Tuberculosis INA status 1 negative test

r- treated for posftlve teslldiseas

Medication Allergies j

r- No Known Drug Allergies

Penicillin (-shy

Yes

Sulfa r- Yes

Codeine

Yes

Morphine - Yes

Aspirin -shy

Yes

IbuprofenlNSAIDS shyYes

Contrast dye (shyYes

Cephalosporins t Yes

Erythromycin -

Yes

Other

other

Other

Other

Other

CurrentAllergies

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

i ~

III I I f I I

I I I

~

I l ~

1 I i ~

I i

i I

Surgical HistolY _

Please indicate if you have had any of the following surgeries

r Ihave had No surgeries Year(sl

r C-Section

r Inguinal hernia shy Right

r Inguinal hernia shy Left

r Hysterectomy Partial

r Hysterectomy Complete

r Tubes Tied

r Breast Surgery

r Heart Bypass

r Knee Surgery - Both

r Knee Surgery - Left

r Knee Surgery Right

r Bacl Surgery

r Gallbladder Removal

r AppendiX Removal

r Cataract Removal

r Colectomy

r Splenectomy

r Tonsillectomy

r AdenOidectomy

r Eariubes

r Sinus Surgery

other

Other

Other

Other

Other

Other

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

middotfamily History

Mothe(s Fathe(s Brothels I Sons I Ir Unknown r Unknown r Unknown I Unknown History History Sisters Oaughte~sr Allergies r Allergies r Anergies rAllergies IHistory History

rEczema r Eczema rEczema r Eczema r Recurrent infections r Recurrent infections r Recurrent infections r Recurrent infections r Asthma r Asthma r Asthma r Asthma r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r Cystic Fibrosis r No Problems r No Problems r No Problems I No Problems

other other Other Other

Social History

Marnal Status Single ( Married ( DivorcedSeparated ( Wklow(er)

SmDfing S1atus -

current every day smoker (

current some day smoker ( former smoker ( never smoker r unknown if ever smofed

smoker - current status unknown ( shySmoking Type f Cigar Cigarettes Pipe

( (- Smo~ng duration NlA 1-5 years 6-10 years ( 11-20 years Over 20 years

- f fMaximum packs per day 112 1112 2or more

Alcohol ( Never r Rarely r Weekly ( Daily

00 you primarily work a Indoors ( Outdoors

Occupation

other

Pediatric Patients

ChiId attends ~ Oaycare r Preschool ( School to Home school ( None

Does child have any brothers or sisters Yes No

other

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Environmental History

Housing r- House ApartmentfCondo (- IIobile homelManufactured home

Foundation I Basement

I Crawlspace

I Slab

Air I None Heating INone CondITioning r Window UnITs I Wood stove

I Central I Central Hot air - Kerosene

I Electric Space Heaters

Other Other

Have WaterI None I None you damageI AC vents I Leaky roof noticed

I Bathroom I Plumbing problemsmold in

I Window frames I Musty odors I Walls I Condensation I Basement I Water stains

other Other

Petsfanimals (Indoor) OtherI None I Cats I Dogs I Birds I Hamsters I Gerbils I RabbITs I Guinea pigs I other

Petsfanimals (Outdoor) I None I Cats [ Dogs Other

I Chickens I Horses [ Goats

~ RabbITs I Cattle I Other

Pests [ None Tobacco r None Bedroom [ Carpet smokeI RoachesflNaterbugs [ Parents I Hardwood exposure

I MicefRats I SpousefPartner I Ceiling Fans [ Grandparent I Humidifier I Caretaker I Sleeps in own bed I Indoor I Shares bed I Outdoor

Other Other Other

Bed Crib mattress Outdoor environment None

Waterbed Construction Allergy mattress cover Timber Stuffed toys Chicken houses Wool blanket Farm

Down pillowcomforter

Allergy pillow cover Standard mattress

other other

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Review of Systems (Current or within the last 12 months)

General - No problems monthsl i--- Failure to thrive r- Fevers

Skin i No problems - Rash

Gaslrointeslinat tlo probfms r-- HeartbumlGERD

r Chills r -Suspicious lesions i--- DifliclJity swalklwing r- SWelits [- Drness i-IJauseft r-- Poor appelie - ~cIling - Vomting r Fatigue -- Boils i-- Abdomilal pain r-- MalaiSe i Hives i- Con2t~atiln r-- ~Ie~hl bss -shy Eczema i-- DilIrrilea r-- See HPI I See HPI r- Change in bowsl hllbls

i JlIUndice

Hean 1-- Uo problems i- Chest pains

1usClllokcletal I No problems Bad pain

r- Bloody stool r- SeeHPI

-- Congenital heart disease C Bone pain -- Pa ~italillns r- Joint pain Metaootie - tJo problems

Passing oul 1- Joint swelmg r Cold mtolellnce Murmur Muscle CIlmpS r- Heat intolerance r- Diffictllty breiHling on exertion - SeeHPI

-- Muscle weall1ess f- Stiffness

- ExcessWe drinking ExcessivE eating

i Arthritis r Excessye urination

UmaryTrad - No problems r- Pain on urination

-- See HPf r- Unexplained weight change r- See liP

- Blood in HIe urine r-- Discharge

Neurologic I No problems - Para~sis Psychiatric INo proble~

r Umul) frequency Weakness 1 H~Peractf-lfty I Bed wetting rSeizures I Behavior problems - Urinal) infectioos i Urinal) stones

- Passing out r Tremors

I Dep ression i- Anxiety

-- See HPJ IDizzmess SeeHPI r See HPI

Hemalologic f ~ No Problem lymphatic r- SweDen glands

- Easy bleeding or bruising See HPI

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

Little Rock Allergy ampAsthma Clinic PA 18 Corporate Hill Drive Suite 110

Little Rock AR 72205 501-224-1156 bull 800-514-4343

PLEASE STOP ANtrHISTAMINES~STbp3 DAY$(j2t16uR~)BEFb~EACtERG~lrE$nNG

THESEj)RUGSSHOULDJ3ESt9~PfD~BEf6REAL~~RGY~IE$IS

Actifed Dallergy Robitussin Cough amp Cold AdvU Allergy Sinus or PM Desloratadine Tagamet Alavert Dimetapp Tavist Allegra Diphenhydramine Triamlli1icCold amp Cough Allegra-D Doxepin Tyend iAllergy or AntLierL ~_ _ _ _~OrootlamJne_lt_gt~- -~ ~~~-cold~M~- ----shyAstelin Nasal Spray Dramamine Unisom Tablets Astepro Nasal Spray Dymista Vazobid Atarax Ed-A-Hist Vicks Children~s Azelastine Famotidine Cold Liquid Benadryl Fexofenadine Xyzal Brompheniramine Hydroxyzine Zantac Cetrizine Levocetirizine Zyrtec or Zyrtec-D Chlorpheniramine Loratadine Chlor-Trimeton Meclizine Eye drops Cimetidine Nyquil Bepreve eye drops Clarinex Patanase Nasal Spray Livostin (Ievocapastine) Clarinex-D Pepcid eye drops Claritin Periactin Optivar eye drops Claritin-D Phenergan Pataday eye drops Cyproheptadine Ranitidine

THE FOLLOWING ANTIDEPRESSANTS SHOULD BE STOPPED 3 DAYS (72 HOURS) BEFORE ALLERGY TESTING (if possible and safe)

Amitriptyline (Elavil) Nortriptyline (Pamelor) Trazodone Adapin Sinequan (Doxepin) Limbitrol Triavil

DO NOT STOP 1 Do not stop asthma medications (Continue inhalers Singulair Accolate Zytlo)

2 Do not stop nose sprays (unless listed above) 3 Do not stop antibiotics and steroids (Continue Prednisone Prelone Medrol or shot) 4 Do not stop steroid or non-steroid skin creams 5 Do not stop all other routine medications (blood pressure diabetes etc)

REVISED 117

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature

I

SPECIALIZINC IN THE DlAwW)SISamp TLjTMEIVTOF ASTHI

ampOTIIpoundR AILpoundRCICIJISfASfs IN ADULTS amp QlLlAAlV

LITILE ROCK ALLERGY amp ASTHMA CLINIC PA

18 CORPORATE HILL DR SUITE 110 LITTLE ROCK An 12205

(501) 224middot1156 (SOD) 514middot4343 FAX (501) 2232625

Gene L France MD JimM-lngram MD

Karl V SitzMD Blake G Scheer MD Stacy S Griffin MD

Kelsy J Caplinger MD (emeritus)

Board Ctrlifted A11trV amp lmmuolovmiddot

PINEBLUFF ALLERGY ASSOCIATES

3900 HICKORY STREET PINE BLUFF AR 71603

(870)5358200 (844)425middot8200 FAX (870)5355954

NORTH LITTLE ROCK ALLERGY amp ASTHMA ASSOCIATES

COM~fERCIAL PARK Il 4620( COMMERCIAL DRIVE STE C

N LITTLEROCK AR 72116 (501)9042820 (800)514-4343

FAX (501)476middot3298

nRYANT ALLERGY amp ASTmlA ASSOCIATES 2301 SPRINGHILL ROAD STE 105

BRYANT AR 72019 (501)2241156 (800)5114343

FAX (501)2232925

CLINICAL RESEARCH CENTER

RESPIRATORY THERAPY SERVlCES

POLLEN COUNTS AT

wwwlittlerockallergycom

Dear Valued Patient

If you are unable to keep your appointment you are asked to provide timetviToticeforcancellatfons pri6Y--toyoufappointnient--ffmeshyUnfortunately in recent years No Show rates for appointments have increased If a patient does not keep a scheduled appointment or does not reschedule prior to 24 hours it will be considered a No Showfl

This creates challenges in scheduling and compromises our ability to provide timely care to all patients needing appointments

Therefore effective April 12 2018 Little Rock Allergy amp Asthma Clinic will be implementing a formal policy that states if a patient has 2 No

Show appointments they will be required to pay a $5000 deposit before the next appointment is scheduled The $5000 deposit will be applied to patient charges if the appointment is kept If the appointment is not kept and results in a No Show the $5000 will be applied to the account to cover the fee for that missed appointment

Thank you for keeping your scheduled apPointments and when needed rescheduling in a timely manner

Date Signature