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Welcome to exemplar allergy and asthma

Your Appointment is on _____________________(date) at _________________________(time). Your Appointment is with: _____Dr. Sally Dee
_____BRIDGEPORT: 153 Main Street,
_____MORGANTOWN: 1063 Maple Dr. Suite 1A,
Bridgeport WV 26330. Phone: (304) 848-2400
Morgantown, WV 26505. Phone: (304)598-2992 (Mon/Wed/Fri)
(Exit 119 off I79. 50E. Across from Benedum Center ) (Off Route 705; “bubble windows” bldg opposite ACE Hardware)
_____FAIRMONT: 100 Avery Olivia Way, Suite B,
Fairmont, WV 26554. Phone: (304) 333-1650 (Tue/Thur)
(Pleasant Valley Road; across from Myer’s Business Park) Checklist before Your Allergy/Immunology Appointment
1. Forms to be Completed and Brought to Appointment.
1. MEDICAL HISTORY FORM
On the Medical History Form, not all questions on the three pages may apply to you. Page 3 applies to everyone, so please fill in all the information on page 3. 2. REGISTRATION FORM (Personal and Insurance Information)
3. (If it applies) Consent Form for Patients less than 18 years-old to be accompanied by someone other
than a parent/guardian. See bottom of the “EXEMPLAR OFFICE PATIENT POLICIES”
2. Stop Antihistamines and medications which would interfere with skin testing, 3 to 5 days before your appointment. See the
“MEDICATIONS WHICH INTERFERE WITH SKIN TESTING” list below. Do NOT stop your other medications, including:
asthma medication, antibiotics, blood-pressure, and other essential treatments. If uncertain, please call your doctor or call us at the
telephone numbers above.
Other forms that are attached:
1. General Information for Exemplar Allergy, Asthma, and Immunology
2. Exemplar Office Patient Policies
Medications Which Interfere with Skin Testing

Prescription Medications: Antihistamines: Discontinue 3-5 days prior to skin testing.
Examples: Astelin, Atarax, Atrohist, Benadryl, Bromfed, Claritin (loratadine), Clarinex, Codimal, Dimetane, Hycomine, Kronofed,
Nolahist, Nolamine, Rynatan, Periactin (cyproheptadine), Rynatuss, Semprex, Sinulin, Trinalin or Optimine, Vistaril (hydroxyzine),
Xyzal, Astelin, Astepro, Patanase, Patanol, Pataday, Bepreve, Optivar, other antihistamine nasal sprays/eye drops/tablets.
Other medications having antihistamine activity which may interfere with skin testing: these medications may need to be
discontinued prior to skin testing, but only after discussions with your allergist and your prescribing physician.
Examples:
Amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), Desipramine (Norpramin), Doxepin (Sinequan), Imipramine (Tofranil),
Nortriptyline (Pamelor), Protriiptyline (Vivactil), Trimipramine (Surmontil)
Over-the-counter Medications: Cold, flu, sinus, and allergy preparations: Discontinue 3-5 days prior
Examples: Actifed, Alka-Seltzer (cold & sinus), Allegra, Allerest, Benadryl (diphenhydramine), Children’s Tylenol (cold & flu),
Chlor-Trimeton (chlorpheniramine), Comtrex, Contac, Coricidin, Dimetapp (brompheniramine), Drixoral, Novahistine Elixir,
PediaCare (cough & cold), Robitussin (cold), Sine-Off, Sinutab (sinus & allergy), Sudafed (sinus & allergy), Tavist (clemastine),
Teldrin, Triaminic, Tylenol (cold, sinus, allergy, flu), Vick’s (cold), Zyrtec (cetirizine)
Night-time pain relievers/sleeping aids: Discontinue 3-5 days prior to skin testing
Examples: Bayer PM, Doan’s PM, Excedrin PM, Nytol Caplets, Tylenol PM, Unisom Sleep Aid
CONTINUE ALL OTHER MEDICATIONS: antibiotics, blood pressure medications, lipid medications, steroids such as
prednisone or Medrol dose-pack, nose sprays (except Astelin), etc. We may not be able to skin test you at the first appointment if you
have been on systemic steroids (oral or injected prednisone, Medrol, etc.) for 2 or more weeks in the previous month. If you can not be
skin tested at the first appointment, you may be skin tested at a subsequent follow-up when you are off antihistamines for 3 to 5 days
and off systemic steroids for 2 weeks before testing.
General Information for Patients of Exemplar Allergy, Asthma, and Immunology We are very pleased that you have selected Exemplar Allergy for your allergy/immunology assessment. This introduction to our
clinic is designed to inform you about our background and policies, and familiarize you with some of the tests and treatments we use
for allergies and asthma. Our practice is open to patients of all ages.
QUALIFICATIONS
Both Dr. David W. Goetz and Dr. Sally Dee are certified by the American Board of Allergy and Immunology (of the American Board
of Medical Specialties). Dr. Goetz is also board certified in Clinical Laboratory Immunology.
ALLERGY CONSULTATIONS
We are ready to help you with a wide variety of allergy, asthma, and immunology problems, including: allergic rhinitis (hayfever),
asthma, food allergy, immunodeficiencies, bee/wasp/yellow jacket/ant venom allergy, latex allergy, reactions to some medications
(e.g. local anesthetics), reactions to immunizations, urticaria (hives) and angioedema, allergic fungal sinusitis, as well as other allergy
related problems.
YOUR PRIMARY CARE PHYSICIAN AND CONTINUED CARE
It is imperative that you have a primary care provider who takes care of your day-to-day medical needs, managing infections,
emergency medical conditions, hospitalizations, and providing your routine medical care.
We will work closely with your
primary care provider in treating your allergic/immunologic or asthmatic problems. However, since we travel among offices in
northern West Virginia and will not always be present in your local area, your primary care provider should be your first contact for
routine and emergency care. Usually we will see you for an initial consult and possibly one or two follow-up visits. Thereafter, your
primary care physician will continue your treatment plan. If you are prescribed allergen vaccine shots, you will be seen in the Allergy
Clinic for yearly reevaluations.
SKIN TESTING
Skin testing is the most sensitive method for identification of the allergenic immunoglobulin, IgE. Exemplar Allergy provides the
newest, gentle and rapid methods of prick skin testing. Our standard allergen panel tests for tree, grass, weed, mold, and
environmental allergen sensitivity. Skin testing can also be done for foods, latex, Hymenoptera (bee/wasp/vespid/ant) venoms, topical
anesthetics, certain drugs, and other allergens. Please be sure that you have stopped taking any antihistamines for 3 to 5 days before
your appointment, because these drugs (Claritin, loratadine, Zyrtec, Allegra, Xyzal, Benadryl, Dimetapp, CTM, and others) interfere
with skin testing. In addition to not taking antihistamines for 3 to 5 days, we may not be able to skin test you at the first appointment
if you have been on systemic steroids (oral or injected prednisone, Medrol, etc.) for 2 or more weeks in the previous month. If you can
not be skin tested at the first appointment, you may be skin tested at a subsequent follow-up when you are off antihistamines for 3 to 5
days and off systemic steroids for 2 weeks before testing.
SPIROMETRY
If asthma is suspected, we will measure your lung function using a spirometer. This is an easy test in which you take a deep breath
and blow as hard, and as long, as you can. The test results are important in both the diagnosis and treatment of asthma.
TREATMENTS FOR ASTHMA AND ALLERGIES
When formulating an allergy or asthma treatment plan for you, we begin with avoidance of identified allergens and irritants. Beyond
environmental management and several useful “home remedies”, there are a variety of medical treatments available. Some
medications relieve symptoms, while others attack the allergic process itself. Allergen vaccines (allergy shots) may be appropriate for
some patients. Our goal is to help you find the best, most effective treatments that relieve your symptoms.
ALLERGY SHOTS
For some patients, allergen immunotherapy may be prescribed in addition to appropriate oral and nasal medications. Allergy shots are
effective treatment for certain selected individuals with allergic rhinitis (seasonal or perennial hayfever) and asthma. Allergen
immunotherapy cannot be given at home or to patients on beta-blocker medications. Shots must be given in a medical office with the
proper emergency equipment for treating reactions, which may occur after receiving allergy shots. Similar to other immunizations,
after receiving an allergy injection there is a 30-minute waiting period before leaving the medical facility. We are available to give
allergy shots in each of our offices in Morgantown, Bridgeport, and Fairmont; however, many patients prefer to receive their
immunotherapy vaccines (allergy shots) at their primary care provider’s office for convenience. (04/08)
EXEMPLAR Allergy and Asthma
MEDICAL HISTORY FORM (All patients please complete this 3 page form)
Please fully fill out any section that applies to you (circle or fill in the answer) Name _______________________________________ Age____________ Male / Female Date_________________________ My primary reason for this appointment: nose or eye allergy / sinus problem / asthma / cough / welts or hives / edema or swellings
/ persisting rash / other reason: ______________________________________________________________________________
Referred by: friend / myself / doctor: ________________________________________________(We’ll send report to this Dr.)
1. NOSE, EYE, OR SINUS PROBLEMS
How Long have you had this problem? _____________________(years/months) Worst season: all year spring / summer / fall / winter Known causes: _______________________________________________________ ____________________________________________________________________ Symptoms BETTER: indoors / outdoors / on vacation / other____________________ Times when symptoms BETTER:_________________________________________ Medications that HELP: _________________________________________________ How many sinus infections a year?_________________________________________ Sinus CAT Scan (date/result):_____________________________________________ Sinus surgery?(date/result):_______________________________________________ ENT surgeon who treated you: ____________________________________________ Allergy testing last done (year)___________where?_______________________________________________________ Treated with allergy shots? From _____to______ Did allergy shots help? Yes / No Stopped because:_______________ 2. PULMONARY RESPIRATORY SYMPTOMS
Do you have asthma? Yes / No Who currently manages your asthma? ___________________________________ Hospital admission for asthma? Yes / No (when?)________________________________________________________ Recurrent cough? Yes / No for how long?___________ Wheezing? Yes / No for how long?_______________________ Rescue inhaler (albuterol) use how often? ____times per day, or ____times per week. Wake to use at night? Yes / No Exercise causes?: Short of breath / cough / wheeze Heartburn/acid reflux? Yes / No Reflux at night? Yes / No 3. ENVIRONMENTAL ALLERGENS AND IRRITANTS
Circle any of the following which aggravate your nose/sinus/lung or skin problem: House dust/cleaning Other animals or allergens ______________________________Chemicals? __________________________________ Other? __________________________________________________________________________________________ 4. ALL PATIENTS please complete this Section
Allergic to bee, yellow jacket or wasp sting? (please describe reaction) _________________________________________________
Smoker? Yes / No How many years?______ How many packs per day?__________ Are there other smokers at home? Yes / No
Medical conditions (not already listed) briefly:____________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Surgeries you have had in the past (with approximate year): _________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Are your immunizations up to date? Yes / No Immunization allergy? ______________________________________
Do you get a flu shot yearly? Yes / No Had the Pneumovax (pneumonia) shot? Yes / No when last?_____________
Family history: Do parents, brothers, sisters, or your children have the following: (circle)
Asthma, Hay fever, Nasal allergy, Sinus, Eczema, Emphysema, Cystic Fibrosis, Lupus, Arthritis, Thyroid
Home: Do you live in a: House / Apartment / Mobile Home Home Near: Lake /Woods /Factory /Farm
Has your home had any water damage/flooding or excessive mold growth?____________________________________
Humidifier used? Yes / No Home Airconditioned? Yes / No
Bed: mattress/waterbed
Home Heating (all that apply): Forced Air / Hot water / Baseboard / Wood stove /Other__________________________
Pests? Ladybugs? Yes / No Cockroaches? Yes / No Other?______________________________________________
Indoor Pets: Cats? #___________Dogs? #__________________ Birds?_________________ Reptiles?_____________
Other pets:_______________________________________________________________________________________
Outdoor Pets/Animals (list type):_____________________________________________________________________
School: Child patient’s current grade in school __________ Adult patient’s current school if any __________________
Patient’s Occupation (adults only)_____________________________ Hobbies________________________________
5. Complete if your problem includes: URTICARIA (Hives) / ANGIOEDEMA, ECZEMA, or RASH
If your problem does NOT include skin problems, please check here ο and CONTINUE ON PAGE 3
My skin problem includes: ____itching, ____hives, ____ swelling? OR _____ eczema/dermatitis/severely itchy skin? How long ago did skin problem begin? __________________. I last had skin problem ___________________________. Continuous? Yes / No. OR Episodic skin problem occurs every _______hrs/days/weeks/months. Where on the body do they occur?___________________________________. They look like?____________________. Do they change location within a day? __________. When gone, do they leave marks in the skin? Yes / No. Things that might cause them? ________________________________________________________________________. Are it/they caused by: ___heat? ___cold? ___pressure? ___tight clothing? ___sun light? ___vibration? ___exercise? ___anxiety? ___latex? ___water? ___food? kind:_____________ medication/vitamin? (list :____________________) Other?____________________________________________________________________________________________.
Associated symptoms? (circle):
NONE, asthma, wheezing, throat tightness, nausea/vomiting/diarrhea, fainting/dizzy, nasal polyps, other ____________
Medications which helped control______________________.Medications which did not help them.________________
Number of Emergency room visits?______ Treatment given: ______________________________________________.
Other treatments or tests done by other doctors for this problem: _____________________________________________
NSAIDS used (circle): Aspirin, ibuprofen, Motrin, Advil, Naprosyn, Orudis, Relafen, Tolectin, Voltaren, Ponstel,
Indocin, Clinoril, Other________ How often do you use an NSAIDS? Daily, every-other-day, weekly, monthly, ___.
List medications which were new for you in the 8 weeks before hives/angioedema/rash began:
Medication:_________________________ Started ______days before skin condition began. Still taking? Yes / No.
On page 3 you will list medications you are allergic to and what happens if you take the medication.
List here medications which you feel are causing your hives/angioedema/rash:
Med:__________________ causes:_________________. Med:______________________ causes:_________________.
List all illnesses/colds which you had in the 8 weeks before hives/angioedema began:
Illness______________________ ;Treatment_______________. Started ______days before hives/etc. Chronic?Yes / No.
Illness______________________ ;Treatment_______________. Started ______days before hives/etc. Chronic?Yes / No.
Do you or someone in your family have one of the following:
Thyroid problems
Asthma, allergies, eczema___ you ___family Other personal or Hepatitis (liver disease) ___ you ___family Do you have problems with feeling cold, constipation, unusually fatigued?____________________________ Before rash began did you change soaps, detergents, cosmetics, hair products, cleaning products?: _______________ _____________________________________________________________ Bath/shower Soap brand_________. Do you use fabric softeners? type________________ Dryer sheets? type_____________________________ Changes in job/school?____________________ New pets or hobbies?________________________________________ 6. ALL PATIENTS please complete this Section
Medication List and Medication / Food / Latex Allergy Questionnaire
1. Medications Currently Used: (If you cannot complete the list, bring all bottles/labels to your appointment.)

2. Medication Allergy If you have NO medication allergies please check here
ο and go on to number 3.
1.Medication

3. Food Allergy If you have NO food allergies please check here ο and go on to number 4.
List all food you do not tolerate & what reaction occurs if you eat or touch the food.:
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
____________________ ______________________________________________________________________________________
4. Latex Allergy/Sensitivity
Latex is the pliable/stretchable material made from the sap of the rubber tree and used in balloons, condoms, elastic bands, padding,
and medical materials.
1. Have you ever had a latex reaction or been told you have an allergy or a sensitivity to latex? Yes / No 2. Have you ever had swollen lips or throat after blowing up a balloon or having dental work? Yes / No Describe if yes:____________________________________________________________ 3. Have you ever had a reaction (rash, swelling, itching of hands or eyes, hives, difficulty breathing) after being in contact with any of the following (circle all that apply): Erasers containing latex Condoms or diaphragms 4. Do you have a congenital condition, such as spinal bifida, myeloma, or myelodysplasia? Yes / No 5. Had multiple procedures involving the spine or use of multiple catheters before 1-year old? Yes / No 6. Are you allergic to the following foods: (circle) bananas, avocados, kiwi fruit, or chestnuts? 1063 Maple Dr. Suite 1A, Morgantown, WV 26505 100 Avery Olivia Way, Suite B, Fairmont, WV 26554
PATIENT INFORMATION

Patient Name (Last, first, middle) ___________________________________________________________
Street_______________________________City_________________________State_________Zip________
Home phone_(AC_______)______________________Email address ________________________________
Date of birth__________________________ Social Security Number_____________________________
Place of employment or school___________________________________Tele # (______)_________________
Primary Care Physician (PCP) _______________________________________________________________
Street___________________________________City_________________________State_________Zip______
PCP telephone #:_(______)___________________________
Pharmacy____________________________City/location__________________ Tele # (______)__________
REFERRED BY_____________________________Heard about Exemplar from:______________
(Please fill out below if patient is a child)
Father’s name___________________________________________________Date of birth________________
Place of employment_____________________________________________________________
Work phone_________________________________Social Security Number_______________________
Mother’s name__________________________________________________Date of birth________________
Place of employment________________________________________________________________________
Work phone_________________________________Social Security Number_______________________
INSURANCE INFORMATION
Primary insurance company _________________________________________________________________
Address__________________________________________________________________________________
Policy Holder’s Name:__________________________________Policy Holder’s date of birth:_____________
Policy Holder’s Social Security Number:__________________________________
Insured’s (Patient’s) I.D. No._______________________________Group Number____________________
Is this an employers insurance plan?_____________________
Secondary insurance company________________________________________________________________
Address__________________________________________________________________________________
Policy Holder’s Name:__________________________________Policy Holder’s date of birth:_____________
Policy Holder’s Social Security Number:__________________________________
Insured’s (Patient’s) I.D. No._______________________________Group Number____________________
Is this an employers insurance plan?_____________________
PLEASE READ AND SIGN BELOW
I authorize any holder of Medical or other information about me to release to the Social Security Administration and HealthCare Financing Administration or its intermediaries or carriers, or to the billing agent of the physician, any information needed for this or related claim. I permit a copy of this authorization to be used in place of the original; and request payment of medical insurance benefits either to myself or the party who accepts assignment. Signed_____________________________________________Date_______________
Exemplar Office Patient Policies
Welcome to our office. We are pleased that you have chosen Exemplar for your medical care. In order for us to provide the quality care that you expect in an efficient manner, we must insist that you read and comply with the following policies. 1. We require reasonable notification (24 hours when possible) of cancellation or rescheduling of all appointments. If three (3) appointments are missed without notification, we will, unfortunately have to
terminate our patient relationship.

2. All insurance cards (including Medicaid) need to be available at the time of each appointment. If the
insurance card information is not available for two (2) appointments, you will need to have that visit rescheduled.
3. If you arrive over 15 minutes late for your appointment, the appointment will have to be rescheduled.
4. If you (the patient) are 17 years old or younger, you must be accompanied by a parent or legal gardian. A
Consent Form signed by a parent or legal guardian is required if the under-18y/o patient is accompanied by another adult. This is a legal requirement and no exceptions will be made. (Please fill out the Consent below and sign.)
5. If you do not have insurance and are paying with check or credit/debit card, you need to pay a minimum of
half of the charges at the time of each visit. The remainder will be due in 30 days.
6. Exemplar offices operate on a cash-less basis. We accept VISA or MASTERCARD (credit card or debit card) or check with proper identification. 7. Authorizations (from your insurance company), if necessary, are also your responsibility and are required on the date of service. Please contact your primary care physician or insurance company with any questions. All co-pays, co-insurance, and deductibles are due in full at your appointment. For questions concerning billing you may contact our billing office: AMBS (Blue Team) at: 800-294-7001 or 304-363-7000. Consent for Child less than 18 years old to be Seen in the Allergy Clinic
If accompanied by someone other than parent/guardian.

I ________________________________, (Parent or legal guardian’s name ) give
__________________________________ (Person accompanying minor patient (must be 18yr or older))
permission to have minor child less than 18 years old ______________________________ (Patient’s name)
seen and given medical care by Exemplar Inc. (AKA, Exemplar Allergy) providers.
_______________________________ _______________________________
Parent or legal Guardian signature Date
______________________________ _______________________________
Witness signature Date

Source: http://www.exemplarallergy.com/images/OnlineApril2010.pdf

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