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1525 E Beltline Ave NE Ste 102 Grand Rapids, MI 49525 Phone: 616-447-7200 Fax: 616-447-9773 RESPONSIBLE PARTY / GUARANTOR INFORMATION (if different than the patient): Payment for services rendered is due at the time of service. As a convenience we accept most major credit cards. If we participate with your insurance carrier(s), we will bill them on your behalf. Your insurance card(s) and your driver’s license or other picture ID must be presented at the time of registration. Co-pays are to be paid at the time of registration. Any co-pay amounts not paid on the date of service will be subject to a statement processing fee. Self-pay and Health Savings Account patients will be required to provide a deposit of 50% of the anticipated charges at the time of registration. If a submitted claim is denied as a “non-covered service,” or if a claim is left unpaid pending further information requested of you by your insurance carrier, then you will be responsible for those charges and mailed a statement from our office. A charge is considered delinquent and will be subject to referral to a collection agency after two statements have been mailed. Verification of current coverage is required for Medicaid and CSHCS patients for each date that a service is provided. Guarantor Form 1525 E Beltline Ave NE Ste 102 Grand Rapids, MI 49525 Phone: 616-447-7200 Fax: 616-447-9773 PRIVACY NOTICE to be completed for all patients: I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that my information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment, whether directly or indirectly. Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that a more detailed Notice of Privacy Practices, containing a more complete description of these uses and disclosures has been made available to me, either in electronic form via website, e-mail or fax, or in paper form. I understand that you (Nancy J. Brooke, MD PC) have the right to change your Notice of Privacy Practices from time to time, and that I may request a current copy of your Notice by contacting you at the address listed above. ADDENDUM to be completed by patients 18 and over: By my signature below, I authorize you (Nancy J. Brooke, MD PC) to disclose my protected health information according to the following terms and conditions: This addendum will expire five years from the date below. I may revoke my authorization sooner by submitting written notification to the attention of the Privacy Officer at the address listed above. Please complete all sections of this form.
If you are filling out this form on behalf of another individual such as your minor child,
please note that the terms “you” and “your” refer to the patient being seen.

Nickname (name that you prefer to be called) Do you have relatives who have been seen in this office? ❑ No ❑ Yes, please list name(s) and give relationship(s): Dr.’s Phone Number (please include area code)
Upper Respiratory Symptoms
How long ago did your symptoms start?
Have your symptoms worsened with each new allergy season? ❑ No ❑ Yes What season or month in the year do your symptoms begin? What month or season do your symptoms stop?
Please check all symptoms that you experience:
Eyes: ❑ Itchy eyes
Nose: ❑ Stuffy nose
Throat: ❑ Postnasal drip
Other symptoms you have experienced that are not listed above: Have you ever had allergy testing? ❑ No ❑ Yes, when? Name of doctor who performed allergy testing
Please check all known triggers for your symptoms:


Nasal Discharge / Sinusitis
Is your nasal discharge usually: ❑ clear ❑ yellow ❑ green ❑ other
Do antibiotics relieve the discolored discharge? ❑ No ❑ Yes ❑ Sometimes Have you had any sinus or nose operations? ❑ No ❑ Yes, when? Name of doctor who performed operation(s) Have you ever had nasal polyps? ❑ No ❑ Yes Have your tonsils or adenoids been removed? ❑ No ❑ Yes, when? Name of doctor who performed operation(s) Patient Form Revised 03/01/2012 PAGE ONE OF TWO Headaches
Are your headaches associated with nasal symptoms? ❑ No ❑ Yes
In what part of the head is your pain located?
Do you experience nausea or vomiting with your headaches? ❑ No ❑ Yes Does bright light aggravate your symptoms? ❑ No ❑ Yes Do you have any history of car sickness? ❑ No ❑ Yes Any diagnosis of migraines? ❑ No ❑ Yes
Ears
Have you had any infections or fluid in the ears? ❑ No ❑ Yes
Has your hearing been tested? ❑ No ❑ Yes, results: Do you experience earaches? ❑ No ❑ Yes Any difficulty with air travel or other altitude changes? ❑ No ❑ Yes Have you had any ear operations, (tubes, patching of eardrums)? ❑ No ❑ Yes, when? Name of doctor who performed operation(s)
Gastrointestinal Symptoms
Abdominal pain or stomachaches? ❑ No ❑ Yes
History of “spitting up” in infancy? ❑ No ❑ Yes History of heartburn (past or present)? ❑ No ❑ Yes Frequent burping? ❑ No ❑ Yes
Skin
Please check any skin problems: ❑ eczema ❑ hives ❑ other give details:
Medications
Please list any medications you have used in treating your symptoms: Antihistamines/Decongestants: How many days of school or work do you miss per year due to your symptoms?
Lab Studies
Date of most recent test(s) and result(s), if known:
CXR

Family History
If any members of your family has allergies, asthma, eczema, hay fever, hives, or migraines, please list the symptoms:
Mother:
Patient Form Revised 03/01/2012 PAGE TWO OF TWO COUGH
Your age when your first cough episode occurred: How often do cough episodes occur that last more than 24 hours? Is the cough present on a daily basis? ❑No ❑ Yes Is the cough worse upon rising in the morning? ❑No ❑ Yes Is sputum or mucus produced with the cough? ❑No ❑ Yes, color of mucus
Is the cough dry and hacky? ❑No ❑ Yes Does the cough ever continue to the point of gagging or vomiting? ❑No ❑ Yes, how often? Does wheezing follow coughing spells? ❑No ❑ Yes
WHEEZING
Your age when your first wheezing episode occurred: How frequently does wheezing occur? ❑Daily SEASONALITY
Are symptoms present all year round? ❑No ❑ Yes Are the symptoms worse during certain seasons? ❑No ❑ Yes, which one(s)? Are symptoms worse in any special location? TREATMENT
Any emergency visits for breathing difficulties? ❑No ❑ Yes, how many times?
Any hospitalizations? ❑No ❑ Yes, how many times?
How rapidly do symptoms progress? (i.e., minutes, hours, days) BRONCHITIS/PNEUMONIA/CROUP/RSV
Bronchitis: How many times?
Any hospitalizations for bronchitis? ❑No ❑ Yes, when?
Pneumonia: How many times?
Any hospitalizations for pneumonia? ❑No ❑ Yes, when?
Croup: How many times?
Any hospitalizations for croup? ❑No ❑ Yes, when?
RSV: How many times?
Any hospitalizations for RSV? ❑No ❑ Yes, when?
COLDS
Do most difficulties seem to result from colds? ❑No ❑ Yes
TUBERCULOSIS
Any family members diagnosed with TB? ❑No ❑ Yes Any fever lasting more than two weeks? ❑No ❑ Yes Any night sweats lasting more than two weeks? ❑No ❑ Yes Any cough lasting more than two weeks? ❑No ❑ Yes Any loss of appetite lasting more than two weeks? ❑No ❑ Yes Pulmonary Survey Form Revised 03/01/2012 PAGE ONE OF TWO ANY COUGH OR WHEEZE FROM ANY OF THE FOLLOWING?
❑ Crying/Tension ❑ Smoke (❑ wood burning ❑ campfires) ❑ Foods: Please check those that apply and record any that are not listed: ❑ Milk ❑ Eggs ❑ Wheat ❑ Smoking ❑ Cigarettes ❑ Cigars ❑ Pipe Medications (if any) that make wheezing worse: PAIN/TIGHTNESS
Chest discomfort with coughing or wheezing? ❑No ❑ Yes, describe the symptom and its location:
MEDICATIONS
Nebulizer: ❑No ❑ Yes
Enter number of puffs and frequency of use for each category of inhaler below and/or doses for oral medications.
List the approximate dates when the medication was used:
Rescue/Short-Acting Bronchodilator (Maxair, ProAir, Proventil, Ventolin, albuterol):
Inhaled Steroids (Flovent [44/110/220], Pulmicort [Inhaler/Respules], Advair [100/50, 250/50, 500/50], Qvar [40/80], Azmacort, Azmanex): Leukotriene Modifiers: (Singulair, Accolate, Zyflo): Long-acting Bronchodilator (Serevent, Foradil): Theophylline (Slo-Bid, Theodur, Theodur 24, Theodur Sprinkles): Oral Steroids (Orapred, Pediapred, Prednisone/Prelone/prednisolone, Steroid Shot): Does any other medicine help the coughing or wheezing? ❑No ❑ Yes, list: Other factors that relieve your coughing or wheezing: OTHER ASSOCIATED SYMPTOMS
Cyanosis (Bluishness): ❑ Lips
❑ Around mouth ❑ Tongue ❑ Finger/Toe Tips Pallor (Whiteness) Face: ❑No ❑ Yes
Anxiety: ❑No ❑ Yes
Retractions: ❑No ❑ Yes
Respiratory Distress: ❑No ❑ Yes
PEAK FLOW METER
1. Do you have a peak flow meter? ❑No ❑ Yes
2. How often do you check your peak flow? 6. Do you have an Asthma Action Plan that is based on peak flow readings? ❑No ❑ Yes Pulmonary Survey Form Revised 03/01/2012 PAGE TWO OF TWO Present occupation (if the patient is a child, please list the occupations of all of the adults in the household)
HOME – MAIN RESIDENCE
City or community where located: ____________________________________ ❑ suburb ❑ rural
Home construction: ❑ frame ❑ brick ❑ mobile home ❑ other
HOME HEATING AND AIR CONDITIONING
❑ natural gas ❑ propane ❑ fuel oil ❑ kerosene ❑ wood ❑ electric Age of furnace:______________ years
❑ forced air ❑ heat pump ❑ hot water ❑ baseboard ❑ space heater ❑ other Air Conditioning: ❑ none ❑ central ❑ room: location(s) Humidifier(s): ❑ none ❑ central ❑ portable: location(s) Electrostatic/Electronic/HEPA filter system: ❑ none ❑ central ❑ portable: location(s)
HOME FOUNDATION
❑ Full or Partial Basement (Please answer the following)
❑ Daylight ❑ Walkout ❑ No operable windows Time spent in basement: ______ hours per wee 5 Basement condition: ❑ Damp ❑ Dry ❑ Leaks Finished? ❑ Yes ❑ No Carpeted? ❑ Yes ❑ No Age of carpeting in basement _____________ years Dehumidifier used in basement? ❑ No ❑ Occasionally ❑ Summer only ❑ Year round ❑ Crawl space with dirt floor ❑ Crawl space with concrete floor ❑ other
LAUNDRY ROOM
❑ None ❑ In basement ❑ On main floor ❑ Located upstairs
Dryer is vented to outside: ❑ Yes ❑ No
BEDROOM/BEDDING DESCRIPTION
Location of patient’s bedroom: ❑ Basement ❑ Main Floor ❑ Upstairs
Bedroom flooring: ❑ Hardwood ❑ Vinyl ❑ Carpet _____ years old ❑ Area rugs _____ years old ❑ Washable Mattress type: ❑ Standard/Innerspring _____ years old. Mattress encased in allergy-proof cover: ❑ Yes ❑ No ❑ Box springs Box springs encased in allergy-proof cover: ❑ Yes ❑ No ❑ Feather ❑ Foam Rubber ❑ Polyfill Pillow(s) encased in allergy-proof cover: ❑ Yes ❑ No ❑ Quilt ❑ Down Comforter ❑ Polyfill Comforter ❑ Sleeping Bag ❑ Blanket ❑ Feather Bed Is a humidifier, vaporizer, or cold steamer used in the bedroom? ❑ Yes ❑ No
FAMILY ROOM/LIVING ROOM DESCRIPTION
Flooring: ❑ hardwood ❑ vinyl ❑ carpet ❑ rug(s) ❑ other
Window coverings: ❑ drapes ❑ curtains Furniture: ❑ fabric ❑ leather Age: SMOKING
Number of smokers in household:_______ Smoking inside? ❑ Yes ❑ No Smoking in car? ❑ Yes ❑ No
Are visitors allowed to smoke in the home? ❑ Yes ❑ No Exposure to smokers elsewhere? ❑ Yes ❑ No
Have you ever smoked? ❑ No ❑ Yes, how much? _______ packs/day, for how long? ________ years
Are you still smoking? ❑ Yes ❑ No
Alcohol consumption: ❑ Never ❑ Rarely ❑ 0-2 drinks/day ❑ 3-4 drinks/day
Environmental Survey Form revised 03/01/2012 PAGE ONE OF TWO PETS
Number of: cats ______ dogs ______ Other pets in home or outside
Are pets: In the bedroom? ❑ Yes ❑ No On the bed? ❑ Yes ❑ No Sleeping with patient? ❑ Yes ❑ No Relatives/Friends with indoor pets? ❑ No ❑ Yes, list number and type of pet: Proximity to: stables ______________________ barns _______________________ dairies
HOME – SECONDARY
❑ Cottage ❑ Non-custodial parent’s residence ❑ Sitter Time spent here:_________ ❑ hours ❑ days per week
Smokers: ❑ Yes ❑ No Pets: ❑ Yes ❑ No
Location of bedroom: ❑ main floor ❑ basement ❑ other:

HOBBIES
Please list hobbies/sports/activities (if the patient is a child, please list those of the adults in the home): Do any of these, i.e., camping or sports, cause increased symptoms? ❑ No ❑ Yes, list and describe symptoms:
CONTACTANTS
Check those items that cause skin irritation: ❑ Poison Ivy ❑ Flowers ❑ Laundry Detergent ❑ Fabric Softener ❑ Dryer Sheets ❑ Chlorine Bleach ❑ Soaps ❑ New Unwashed Clothing ❑ Cosmetics
INSECT STINGS

IF FOOD ALLERGIES ARE SUSPECTED List the food(s) you suspect cause an allergic reaction and describe
the reaction, the timing of the reaction in relationship to ingesting the food, its duration, characteristics, etc.:

PAST MEDICAL HISTORY
Medical problems (diagnosis, date)
Drug allergies (List drug and describe reaction) Hospitalizations or Emergency Room visits (List all and year) Other medications not listed above (vitamins, herbals, BCP, etc.): Are immunizations up to date? ❑ Yes ❑ No Check all immunizations received: ❑ MMR ❑ DPT ❑ HIB ❑ Polio Injection (IPV) ❑ Oral Polio (OPV) ❑ Influenza ❑ Pneumovax ❑ Prevnar ❑ Hepatitis B / Heptavax ❑ VariVax (chicken pox) ❑ Other
SOCIAL HISTORY
List family members currently residing in home:
Sitter/Daycare: ______ hours/week Smokers at daycare? ❑ Yes ❑ No Pets at daycare: Grade in school: _____________ Pets at school (list): Environmental Survey Form revised 03/01/2012 PAGE TWO OF TWO

Source: http://nbrooke.comcastbiz.net/forms/forms_pack.pdf