ThankyouforchoosingAllergyAssociatesofUtahforyourmedicalcare.Pleasecompletetheincludedallergyquestionnaireandreturnitbymail(iftimepermits)orbringitwithyoutoyourappointment.Ifyoudonothavetimetocompleteitbeforeyourappointment,pleasearriveatourofficeatleast30-45minutesearlysoyouwillbereadyintimeforyourappointment.Ifyouwouldliketosendinyourpaperworkorany additionalmedical records electronically, please contact our office, and the staffwillwalk you through theprocess.Pleasemakesuretobringacurrentcopyofallactiveinsurancecard(s)andyouridentification/driver’slicensetotheappointment.ANALLERGYEVALUATIONCANTAKEUPTOTWO-THREEHOURS.Pleasedonotscheduleanyotherappointmentsthatmayconflictwithyourallergyappointment.The providermay perform testing to evaluate yourmedical condition. The type and number of testsmay varydependingonthemedicalproblem.Iftestingneedstobeperformed,youshouldAVOIDthefollowingallergymedicationsforthespecifiedtimes:• Claritin(Loratadine),Allegra(Fexofenadine),Zyrtec(Cetirizine),Clarinex,Xyzal,Hydroxyzine,Vistaril–72hours• Benadryl(Diphenhydramine),Lodrane(Bromphenaramine),Chlorpheniramine,DAllergy,Allerx–48hours• Anyotherantihistamineoranti-itchpill,cough/coldmedication,orallergypill–Checkwiththeoffice• Astelin(Azelastine),Astepro,Dymista,orPatanase(Olapatadine)NasalSpray–48hours• Patanol (Olapatadine), Pataday, Zaditor (Ketotifen), Optivar (Azelastine), Elestat (Epinastine), or other anti-

histamineallergyeyedrops–48hours• Zantac(Ranitidine),Pepcid(Famotidine)–48hoursYOU SHOULD NOT STOP ANY OTHER MEDICATIONS, INCLUDING ASTHMA MEDICATIONS, STEROIDS, ORANTIBIOTICS,UNLESSDIRECTEDBYAHEALTHCAREPROVIDER. If youhaveanyquestions, please call ourofficebeforeyourappointment.We routinely contact your insurance for a good-faith estimate of your benefits for ourmost routine tests andprocedures.Wewilldiscusswithyouwhenthesetestsmaybemedicallybeneficial.Copayments for specialist office visit services are due at time of service and/or a good-faith estimate of yourdeductibleandcoinsuranceasdeterminedbyyourmedicalplanatthetimeofservice.AnyquestionsorpaymentarrangementscanbemadewiththeBusinessOfficepriortoyourvisitat(801)263-8700,option1.Pleasenotifyourofficeatleast24-48hoursbeforeyourappointmentifyouareunabletokeepit.Welookforwardtomeetingyouandhelpingyouwithyourmedicalcare.Sincerely,AllergyAssociatesofUtahwww.utahallergies.comoffice@utahallergies.com

ALLERGYASSOCIATESOFUTAHPatientInformation

Name: DateofBirth: / / Date: / /

Address: City: State: Zip:

HomePhone: CellPhone: Occupation:

EmergencyContact:

Relationship: Phone: Address:

PersonalPhysician: Referredby:

Pleaselistotherfamilymemberswhohavebeenseeninthispractice:

ResponsibleParty

IFTHEPATIENTISANADULT IFTHEPATIENTISAMINOR

Employer:

WorkPhone:

Spouse:

Employer:

WorkPhone:

Responsiblepartyname:

Address:

City: State: Zip:

HomePhone:

Employer:

InsuranceInformation

1stInsuranceCompany:

SubscriberName:

SubscriberDateofBirth:

SubscriberID#:

SubscriberGroup#:

2ndInsuranceCompany:

SubscriberName:

SubscriberDateofBirth:

SubscriberID#:

SubscriberGroup#:

NOTE:IFYOURINSURANCECOMPANYREQUIRESAREFERRAL,PLEASEGIVEYOURCURRENT,COMPLETEDREFERRALFORMSFROMYOURPRIMARYCAREPHYSICIANASWELLASYOURINSURANCEIDCARDTOTHEFRONTDESKBEFOREYOUSEETHEDOCTOR.ITISYOURRESPONSIBILITYTOCOMPLYWITHTHETERMSOFYOURCONTRACTWITHYOURINSURANCECOMPANY.

CREDITPOLICIES1. PAYMENTISREQUESTEDATTHETIMEOFTREATMENTUNLESSSPECIALARRANGEMENTSAREMADE.2. PAYMENTONACCOUNTSBILLEDISEXPECTEDWITHIN30DAYS.

Nofinancechargewillbemadeunlesstheaccountisnotdischargedasperagreement.I/Weacknowledgethisagreementandagreetopaycollectioncostsand/orreasonableattorney’sfeesifanydelinquentbalanceisplacedwithanagencyorattorneyforcollectionsuit.

Patient/ParentalSignature: Date: / /

PatientName:_____________________________________________________________ DateofBirth:____/____/______

08/01/2016-1-

AllergyQuestionnairePatientName:_________________________________________DateofBirth:____/____/______Date:____/____/______Describethetypicalsymptomsinyourownwords:

Haveyouhadpreviousallergytesting? No Yes(Whenandbywhom):___________________________________________Pleasefilloutthefollowingsections:

1. Allergies(Nose,Eyes,Sinuses) Doesnotapply

Symptoms Howoften? Howbad? Never Rarely Somedays Mostdays Daily Mild Moderate SevereNasalcongestion

Runnynose

Post-nasaldrip

Sneezing

Cough

Eyeitch

Eyewatering

Headache

Earsymptoms

AllergyTriggers:

Trees Grass Weeds Mold

Cats Dogs Dust Horses

Strongodors/chemicals Coldair Exercise Infection

Winter Spring Summer Fall

Other: Unknown NONE

PatientName:_____________________________________________________________ DateofBirth:____/____/______

08/01/2016-2-

2. Breathing Doesnotapply

Ihave: Breathingsymptoms Asthma COPD Other

Symptoms Howoften? Howbad? Never Rarely Somedays Mostdays Daily Mild Moderate SevereShortnessofbreath

Chesttightness

Wheezing

Cough

BreathingTriggers:

Trees Grass Weeds Mold

Cats Dogs Dust Horses

Strongodors/chemicals Coldair Exercise Infection

Winter Spring Summer Fall

Other: Unknown NONE

3. FoodReactions DoesnotapplyWhatnoworinthepasthascausedtrouble?

Whatwasthereaction?

4. RashesandHives DoesnotapplyWhatnoworinthepasthascausedtrouble?

Whatwasthereaction?

5. InsectStingReactions DoesnotapplyHasthepatienteverhadaseverereactiontoabee,wasp,orhornetsting?

No

Yes(Describe): _______________________________________________________________________________

PatientName:_____________________________________________________________ DateofBirth:____/____/______

08/01/2016-3-

Medical,Family,andSocialHistory

1. MedicalProblemsandSurgeriesPleasecheckanyofthefollowingmedicalproblemsorsurgeriesthatyouhavehad:

MedicalProblems Surgeries

NONE NONE

Asthma Migraines Sinus Heartvalve

COPD Arthritis Nasalpolyp Cataract

Tuberculosis Rheumatoidarthritis Nasalseptum Colonscope

Allergies Depression Othernosesurgery Gastricbypass

Nasalpolyps Anxiety Tonsils Intestinalsurgery

Chronicsinusitis Otherpsychiatric Adenoids Herniarepair

Reflux/heartburn Heartdisease Eartubes Hemorrhoids

Pepticulcerdisease Heartattack Appendix Breastbiopsy

Lowthyroid Heartfailure Gallbladder Breastaugmentation

Highthyroid Chestpain Thyroid Breastremoval

Highbloodpressure Stroke Hysterectomy Hip

Highcholesterol/lipids Transientstroke D&C Knee

Diabetes Cancer Caesareansection Back

Kidneystones Heartbypass

Other:

Other:

2. FamilyHistory

Pleasecheckandlistanymedicalproblemsthatruninyourfamily:

NoProblems

Unknown Allergies Asthma FoodAllergies

Eczema Other(Pleaselist)

Father

Mother

Brothers( none)

Sisters( none)

PatientName:_____________________________________________________________ DateofBirth:____/____/______

08/01/2016-4-

3. SocialHistory

HousingType: Apartment

Singlefamilyhome

Condo

Other: _______________________________________________________________________________

MaritalStatus: Single Divorced

Married Widowed

Separated Other

Occupation: _____________________________________________________________________________________________

Doyousmoke? No

Yes-> Forhowlong? ______________________________

Howmanypacksperday?_______________________

Former-> Whendidyouquit? _______________________

Howlongdidyousmoke? _______________________

Howmanypacksperday?_______________________

Doyoudrinkalcohol? No

Yes

Former

Anypetsathome? No

Yes

Cat(s)

Dog(s)

Other:_______________________________

Doyouhaveaprimarycarephysician? No

Yes: _________________________________________________________________

Didaphysicianreferyou? No

Yes: _________________________________________________________________

Howdidyouhearaboutus? _______________________________________________________________________________

PatientName:_____________________________________________________________ DateofBirth:____/____/______

08/01/2016-5-

MedicationAllergiesandMedicationsPleaselistanyreactionstomedications: NONE

MedicationName Reaction ApproximateDate/Age

Pleaselistanymedicationsyouarecurrentlytaking: NONE

MedicationName Strength Dose Frequency

NOTES

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ElectronicCommunicationPolicy

Thispolicyappliestoelectroniccommunications(theonlinepatientportalande-mail).Pleaseusetheonlinepatientportalwheneverpossibleinsteadofe-mailforenhancedsecurityandprivacy.

1.Noemergenciesorurgentmessages.Electroniccommunicationisnottobeusedforemergenciesorurgentmessages.WedonotmonitorourIn-Boxconstantly.Youcansendamessageanytime,butwemaynotreadituntil the next business day.We checkmessages during regularwork hours, and answer them in theorderreceived.Wetrytodealwithmessageswithin1workday,butcircumstancescouldcauseustofallbehind.Usethetelephoneifyouneedaresponserightaway.Ofcourse,inalife-threateningemergencycall911.

2.Uses.Ourpracticeacceptselectroniccommunicationmessagesforthesepurposes:

a.Generalmessageslikemakingorchangingappointments,billingissues,orotherquestionsthatcanbeansweredbyanyappropriatestaffperson.

b.Medicalquestions.Ourprovidersmaygive theirprofessional E-mail addresses toyou formedicalquestions.Althoughtheymightsometimesreplyafterhours,youshouldnotexpectproviderstomonitortheirmailcontinuously.Evenon-call, it’s likelytheproviderisnotsittingatacomputer.Again, ifyouhaveaproblemthatneedsattentionrightaway,usethetelephone.

c.Prescriptionrenewals.Youcanrequestrefillsofmedicineswehavepreviouslyprescribed,thesamewayasleavingaphonemessage.Ifwehaveaquestionforyou,wemayrespondbyE-mailorphone.

3.Partof the record. Electronic communicationmessagesare consideredpartof yourmedical record.Ourpolicies for recordprivacyandappropriateusesofmedical informationapply tomessageswesendtoeachother.

4. Security. Youneed toprotect theE-mail address yougiveus, tomake sureour communications remainprivate.ThisistheonlywaywecantrustthatmessagesfromyourE-mailarereallyfromyou,andmessageswesendarenotgoingtosomeoneelse.Ifwearen’tsureaboutamessage,wewilltrytocontactyouinsomeotherway.

5.Availability.Ifyouaskustouseelectroniccommunicationtocommunicatewithyou,wewillassumethatyoucheckyourIn-Boxatreasonableintervals.Wedon’tguaranteethatwewillrespondtoyourmessagesandweunderstandyoucan’tguaranteethatyouwillrespondtoours.Incasesofuncertainty,wewilltryotherwaysofcommunicating.

2of2

ElectronicCommunicationPolicy(cont.)

6.Sensitivemedicalinformation.Wecan’talwaysknowwhatinformationyouconsiderespeciallyprivate.Wetakecarewithallmedicalrecords,butweknowthatsomefactsaremoresensitivethanothers.BecauseE-mailcan’tbeguaranteed100%secure,pleasedon’tputextremelysensitivemattersinmessageswithoutconsideringthis.Theonlinepatientportalprovidesenhancedsecurity.

7. Voluntary. Using electronic communication is voluntary for both of us. If we feel you are using E-mailinappropriately(or,ifwethinkyouraddresshasbeenhackedbyanimposter),wemayblockyourmessages.Ifyoudecideyoudon’twanttoreceiveE-mailfromusanylonger,justletusknow.

8.Changesofaddress.IfyourE-mailaddresschanges,youneedtoletusknow.

9. Non-essential uses.Wewill only use your E-mail address for important communications related to ourpractice.WewillnotgiveyourE-mailaddresstoanyonewhoisnotpartofourpractice.Pleasedon’tsendnon-essentialmessagestous,becausetheyslowdownourabilitytorespondtotheimportantones.

10.Mistakes.Mistakeshappen. Ifyoubelieveyouhavereceivedorsentamessagebymistake,oronethatcontainserrors,pleaseletusknow.Youshoulddeletemessagesthatarenotintendedforyou.

11.Otherrisks.Inadditiontothoseabove,electroniccommunicationcanhaveotherrisksanddisadvantagesthatmight cause inconvenience or harm. Everyone using E-mail needs to use good judgment about thesevaluabletechnologies,andmustrememberthattherearealternativesthatwouldbebetterforsomesituations.

AcknowledgementandAgreement

I acknowledge that I have read this form. I understand that electronic (online) communication has risks,includingpossiblerisksnotmentionedabove.Iagreetoabidebythepoliciesdescribedabove.IagreetousereasonablejudgmentwithregardtoanymessagesIsendorreceive.IdonothaveanyunansweredquestionsaboutwhatthisAgreementrequires.

Patient(orlegalrepresentative)name:_________________________________________________________

Signature:_____________________________________________________Date:____/____/______

IwouldliketosignupfortheOnpatientpatientportalandreceivee-mailremindersformyclinicalcare.

E-mailaddresstobeused:____________________________________________________________________

Iwouldliketoreceivetextmessageremindersformyclinicalcare.

Phonenumbertobeused:____________________________________________________________________