Order Form

Asthma & Allergy Associates, Sterling/Troy, P.C.
Brandon D. Ross, M.D.
Dr. Anne Erben, M.D.

2950 East Wattles Road, Suite 300
Troy, Michigan 48085
Tel: (248) 524-2121
Fax: (248) 524-2035

Registration Form
Date*

MonthDayYear
Birth Date*

MonthDayYear
Patient Name*
Social Security Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone*
E-Mail*
Sex*

MaleFemale
Marital Status*

SingleMarriedWidowedSeparatedOther
Patient Employed By*
Work Phone*
Employer Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation*
Responsible Party (If Minor)*
Birth Date*

MonthDayYear
Is the responsible party's address different?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Relation
Do you have medical insurance?*

YesNo
If yes: Name of Primary Insurance:*
Card Holder ID/Contract #*
Group #*
Card Holder Name*
Date of Birth*

MonthDayYear
Card Holder Employer*
Do you have secondary medical insurance?*

YesNo
Name of Secondary Insurance*
Card Holder ID/Contract #*
Group #*
Card Holder Name*
Date of Birth*

MonthDayYear
Card Holder Employer
Emergency Contact*
Phone*
Relation*
Primary Doctor’s Name*
Phone*
How did you learn of our practice?
THERE WILL BE A $25.00 CHARGE FOR CANCELING AN APPOINTMENT WITHOUT A 24 HOUR NOTICE.ALL CO-PAYS, CO-INSURANCE, DEDUCTIBLE AND UNCOVERED SERVICES WILL BE THE RESPONSIBILITY OF THE PATIENT OR THE PARENT OR GUARDIAN WHO BRINGS THE PATIENT IN AT THE TIME OF SERVICE. WE CAN GIVE YOU AN ITEMIZED RECEIPT IF YOU REQUIRE ONE.
INITIALS*

Clear
DATE*

MonthDayYear
Assignment and Release

I, the undersigned, have insurance coverage with
and assign directly to Dr. Brandon Ross all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions.
Signature of Insured / Guardian

Clear
Date

MonthDayYear
Medicare Authorization
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Brandon Ross for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in the item 98 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.
Signature of Insured / Guardian

Clear
Date

MonthDayYear
ALLERGY / ASTHMA QUESTIONNAIRE
DATE*

MonthDayYear
NAME*
D.O.B:*

MonthDayYear
AGE*
Are you taking any medications? (Including Vitamins / Inhalers)*

NoYes (if yes fill out medicine sheet including drug allergies)
Medication Sheet
DRUG ALLERGIES (include reaction and date):*

Street Address Line 2

CityState / Province

Postal / Zip Code
Name:*

Reason for today's visit*
Ever been to ER or hospitalized relating to this problem?*

YesNo
Where?*
When?*
Associated symptoms

SneezingItchingHivesSwellingStuffy noseRunny noseRashShort of breathWheezingCoughOther
Has anything helped the condition?
Which seasons, if any, are your symptoms worse?
Select any of the below which make your symptoms worse:

ExerciseSmokeCold AirFoodsDustIrritantsMoldStressPetsCosmeticsColds/FluEmotionCut GrassChemicalsHumidityWeather ChangeBeing OutdoorsBeing IndoorsNightMorning
Symptoms you are currently having
Heart*

Chest PainDizzinessPalpitationsNONE
Lungs*

Breathing DifficultyProblem with breathing w/exerciseChest TightnessShortness of breathWheezeCoughNocturnal symptomsNONE
Nose*

BleedingCongestionDry MouthMouth BreathingNasal SpeechRunnyLoss of Taste or SmellSnoringSneezingNONE
Eyes*

Dark CirclesContactsGlassesItchyRedRunnySwollenNONE
Ears*

ItchyPainPluggedPoppingRingingNONE
Throat*

ScratchyPainPost Nasal DripThroat ClearingVoice ChangeTrouble SwallowingNONE
Skin*

SwellingDryFlushingItchingHivesRashNONE
Constitutional*

Loss of AppetiteFatigueFeverPoor SleepWeight GainWeight LossNONE
Gastro Intestinal*

ConstipationDiarrheaNauseaAbdominal PainRefluxVomitingNONE
Muskoskeletal*

SwellingNONEPain
Sinus*

HeadacheFace PainTMJPressureTeeth PainNONE
Neuro/Psych*

AnxietyDepressionNONE
Other
Allergy History
Have you been tested for allergies before?*

YesNo
If yes: By whom?*
When?*
How were you tested?*
Have you ever received allergy injections? *

YesNo
Year Started:*
Date of last injection:*
Any adverse reactions?
Have you had an adverse reaction to contrast dye? *

YesNo
Have you had an adverse reaction to latex?*

YesNo
Are symptoms caused or made worse by foods?*

YesNo
Which ones?*
Have you ever had a severe reaction to an insect sting? *

YesNo
What insect?*
Have you ever had a rash after coming into physical contact with something:*

YesNo
What was it you were coming into physical contact with?*
Have you had any pulmonary testing in the past year? *

YesNo
By whom?*
Have you had a chest x-ray in the past year? *

YesNo
By whom?*
Have you had a sinus x-ray in the past year?*

YesNo
By whom?*
Past Medical History*

AsthmaCOPDEczemaHigh Blood PressureHeart DiseaseMigraineDiabetesRefluxDepressionAnxietyADDThyroid DiseaseRecurrent InfectionsNone of the above
Other
Surgeries:
Is the patient under the age of 12?*

YesNo
Birth History

NaturalCaesarean
Induced:

YesNo
Birth Weight
How many weeks pregnant at delivery?
Any Complications?:

YesNo
Did the patient require oxygen at birth?:

YesNo
If yes, how long?
Was the patient intubated(on a ventilator)?

YesNo
If yes, how long?
Was newborn taken home on time?:

YesNo
If in NICU, for how long?
Social History:
School grade or occupation:*
Day Care (if child)

YesNo
Marital Status*

MarriedSingle
How much school or work have you missed in the past year?*
Chewing tobacco use?*

YesNo
How long
Year Quit

MonthDayYear
Have you ever smoked?*

YesNo
How much?
How long
Year Quit

MonthDayYear
Do you drink alcohol?*

YesNo
Amount per week*
How much caffeine do you drink in a day?*
Recreational drugs use? *

YesNo
Frequency and which drugs:*
Traveled in the past six months prior to the onset of symptoms?*

YesNo
Where to?*
Hobbies/leisure activities:*
Who else live in the home?*
Family Medical History:
Any family history of asthma, allergies or eczema?

YesNo
Mother:*

LivingDeceased
Age:*
Medical problems:*
Father:*

LivingDeceased
Age:*
Medical problems:*
Brothers/Sisters:

LivingDeceased
Age:
Medical problems:
Environmental:
If patient is a child are they living in 2 different households?

YesNo
Are you exposed to second hand smoke?*

YesNo
If yes, is exposure at*

HomeWork
other*
Does school or your job cause or worsen your condition?*

YesNo
Any exposure to chemicals or fumes?*
Dwelling
What is the primary residence?

HouseApartmentMobileFarm
Other
Primary Residence
Is dwelling?*

DampDustyNeither
When did you move in?*
When was it built?*
Basement?*

YesNo
If, Yes*

DampDry
Carpet in home?*

YesNo
Wood Burning Stove? *

YesNo
Central Air?*

YesNo
Pillows: *

PolyesterFeather
Pillow Age:*
Mattress age:*
Do you have any pets?

YesNo
What kind of pets and how many?
Do you have a secondary residence?

YesNo
HouseApartmentMobileFarm
Is dwelling?

DampDusty
When did you move in?
When was it built?
Location of the Residence
Time spent in the Residence
Basement?

YesNo
If,Yes

DampDry
Carpet in home?

YesNo
Wood Burning Stove?

YesNo
Central Air ?

YesNo
Pillows:

PolyesterFeather
Pillow Age:
Mattress age:
Do you have any pets?

YesNo
What kind of pets and how many?

	Medication Name	Dosage
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3
4
5
6
7
8
9
10
11
12

Registration Form

ALLERGY / ASTHMA QUESTIONNAIRE

Medication Sheet

Symptoms you are currently having

Allergy History

Social History:

Family Medical History:

Environmental:

Dwelling

Primary Residence

HIPPA