Medication List

Directions:

Please be sure to hit SUBMIT at the end of this page

THIS FORM MUST BE COMPLETED ENTIRELY BEFORE THE PHYSICIAN CAN SEE YOU DUE TO REGULATIONS BY THE FEDERAL GOVERNMENT AND INSURANCE PLANS.

FOR MEDICAL STAFF:

BP_______ P______ R______ TEMP_______ PF______BMI______

Patients First Name

Patients Last Name

PATIENTS DOB:

Email address

EMAIL IS NEEDED TO IDENTIFY PAPERWORK

Patients Height

Patients Weight

Patients BMI (if known)

Are there any changes to the following?

Address

Phone Number

Primary Insurance

Secondary Insurance

Primary Care Doctor

New Address:

New Phone Number:

New Primary Insurance Name:

Insurance ID Number:

Is the patient the subscriber?

Yes No

Subscriber Date of Birth:

Subscriber Name:

New Secondary Insurance Name:

Insurance ID Number:

Is the patient the subscriber?

Yes No

Subscriber Date of Birth:

Subscriber Name:

New Primary Care Doctor:

Primary Care Doctor Phone Number:

List all medications you are currently taking. INCLUDING medications NOT prescribed by us.

Medication # 1:

Medication # 2:

Medication # 3:

Medication # 4:

Medication # 5:

Do you take any more medications?

Yes No

List additional medications & indicate if you need a refill

Are you allergic to any medications?

Chief Complaint:

Symptoms/ Problems as previously discussed, current/ ongoing

I, the undersigned, give consent to ACADEMIC ASSOCIATES IN ALLERGY, ASTHMA, & IMMUNOLOGY (ALLERGYTAMPA.COM) to view my or my child’s prescriptions history.

Preferred Pharmacy

Name of pharmacy

Pharmacy Phone Number

Signature of Patient or Legal Guardian

By typing your name above you consent to electronic signature

Tobacco User?

Yes No

If yes, do you want counseling on smoking cessation?

Yes No

Do you want counseling on weight regulation?

Yes No

Have you received the flu vaccine for the current year?

Yes No

Have you received the COVID-19 vaccine?

Yes No

ASTHMA CONTROL TEST

Total Score

Add the numbers in parentheses. If your total score is 19 or less, your asthma may not be as well controlled as it could be.

Thank you. Additional comments are appreciated.

Your information will be encrypted.

Medication List

Directions:

Directions:

Drs. Lockey, Glaum, Cho, Dzoba, & Pepper