The following History Form must be filled out completely -
every question answered - prior to an appointment being set up for initial
assessment by Dr. Sweet. Initial office assessments are by appointment on
Tuesdays (10:15 a.m. to 3:15 p.m., Sept. to April). Allergy
testing is never done during this initial 15 minute assessment - the purpose of
this assessment is to complete a physical exam, review the history provided,
review all meds/pills/herbals being taken, to determine if allergy testing is
appropriate (and to decide on what to test you for). Dr. Sweet is away from May through August every year.
All assessment and testing is done; and all appointments are made; from Sept. to April. The office is closed on Thursdays &
Fridays. Forms and referrals received during the summer are processed in early
Sept.
You can download this form, fill it out, and email it back to Dr.
Sweet Note: once you are viewing
this form on your internet browser, you will want to edit this form with your
word processing program – for the latest Internet Explorer, you would
click on the “Page” tab, then click on edit with MS Word, fill the
form out, then save as a specific named document on your computer, then send to
me via email as an attachment. For those
who cannot do this; send me an email
asking for the History Form, I will email it back to you, you can fill it out
with your word processing program, save, and then email it back to me as an
attachment.
OR
You can print this form, fill it out, and : 1 - Mail it to Dr.
Sweet’s office at: Thunder Bay Medical Center, 63 N. Algoma St., suite
110, Thunder Bay, ON, P7A4Z6.
2 - Fax it to 807-345-1891 (Sept. to April).
3 - Drop it off at the office on Tuesdays
(9a.m.-5:00p.m.,Sept. to April).
Out of town patients are ALWAYS assessed on Tues. p.m. and
are skin tested the next morning ( Wed. a.m.).
If out of town patients wish specific testing dates, contact my office to see
if these dates are available. Otherwise, appointment
dates, times , and instructions will be mailed or
emailed to you.
For
local patients : Once you have
completed this History Form, e mail it back to me at : sweetb@tbaytel.net and your
initial appointment will be sent to you by email. Local (in town) patients must set up their
initial appointment from Sept. to April by dropping down to my office on any
Tues. between 9:30 a.m. and 4:00 p.m.; by fax at 807-345-1891; or by email at sweetb@tbaytel.net
DISCLAIMER : there is no guarantee of
confidentiality of your health information when you complete and email
this History Form and Dr. Sweet assumes no responsibility for
a breach of confidentiality or any misuse of the information provided. If you wish to guarantee confidentiality, you
must come to my office on a Tues. 9:30 a.m. to 4:00 p.m. and fill the History
Form out personally or mail-fax printed version.
fill in details where you see .……..
HISTORY
CHART FOR ALLERGIC DISEASES
NAME
(last)....
(first).... male/female
ADDRESS....
HEALTH
CARD # ..... (include letters) ** *email address……………..
BIRTH
DATE ....
PHONE ....
POSTAL CODE ....
work
PHONE ....
FAMILY DR.
....
answering machine? yes / no
Occupation
…….
Hobbies……
PRESENT
COMPLAINT (underline or list....) ( please
identify your MAIN Complaint)
fatigue
runny/plugged nose sneezing headache
sinuses hives skin rash ear
infections eczema itching diarrhea bloating wheezing coughing difficulty
breathing eyes other???..……………..
QUESTIONS
ABOUT YOUR PRESENT COMPLAINT
-when
did this first start
...
frequency ...
duration ...
-any
change/anything new prior to the start ....
-is
complaint worse (underline) :
outdoors
indoors at
home at
work upon waking up at night daytime
when humid when dry dusty areas ??? ....
-worst
seasons: spring summer
fall
winter
worst month ....
-is
complaint: constant or variable (how?) ....
-is
complaint made worse/caused by certain :
foods ....
(please list) smells ....
contact/exposure
to things/pets/etc.....
PREVIOUS
ALLERGIC HISTORY (underline or list....)
-have
you or relatives(identify which relative) ever had : eczema
asthma bronchitis migraine sinus hayfever
hives nasal polyps food
sensitivity ??? ....
MEDICAL
HISTORY
-past or
present problems: heart lung bowel thyroid diabetes ??? ....
-List
All Current Medications/Pills/Vitamins/herbals :
(bring ALL to first appointment)
....
-Drug
Allergy / Reactions : (list ....)
.....
EXPOSURE
HISTORY
-are you
often in contact with (underline) : feathers dogs cats
birds horses rabbits rats cattle turtles
fish hamster gerbil guinea
pig ferret ??? ....
Pets in
the bedroom??.... yes /
no
-do you
/ your spouse / your parent(s) smoke
: yes / no smoke
inside/in vehicle yes/no
-do you
live in : city core / small town / country ;
apartment / house / rented
-does
your home-apartment have : carpets (lots / in bedroom), wood heat (inside / out),
wood
stored inside, forced air heat, open windows, full basement (damp / dry),
visible
mold/mildew, central air, visible moisture, good drainage
around the outside,
air
exchanger, previous flooding, pets, recent renovations
PREVIOUS
REACTION TO : stinging insects
/ nuts / seafood or fish / ASA ??? (describe....)
....
Additional
Information ? : ……...
******IF
YOU WANT YOUR INITIAL APPOINTMENT TO BE MADE AND SENT TO YOU INDICATE HERE
>>>>>>___________******
(whenever
possible appointments will be sent by email)
DID YOU FILL IN
YOUR HEALTH CARD # ????? THIS
MUST BE DONE
ALL
APPOINTMENTS CAN BE CANCELLED (Sept. to April) BY CALLING 807-345-7555,
PRESSING 2, AND LEAVING DETAILS, BUT MUST BE DONE AT LEAST 48 HRS. PRIOR TO
YOUR APPOINTMENT TIME OR YOU WILL BE CHARGED FOR CANCELLATION.
APPOINTMENTS MUST BE CONFIRMED ONE
WEEK PRIOR BY EMAIL : sweetb@tbaytel.net or your appointment will be given to another
patient.
end
Dr. H. Bruce Sweet , 2011