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

In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work or at home?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

During the past 4 weeks, how often have you had shortness of breath?

More than once a day

Once a day

3 to 6 times a week

Once or twice a week

Not at all

During the past 4 weeks, how often did your asthma symptoms (wheezing , coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning?

4 or more nights a week

2 to 3 nights a week

Once a week

Once or twice a week

Not at all

During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? NOTE: Using before exercise or with exercise does not count

3 or more times per day

1 to 2 times per day

2 or 3 times per week

Once a week or less

Not at all

How would you rate your asthma control during the past 4 weeks?

Not controlled at all

Poorly controlled

Somewhat controlled

Well controlled

Completely controlled

Total Score

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, & Pepper