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COOL SPRINGS ALLERGY ASSOCIATES, P.C. / CLARKSVILLE ALLERGY CLINIC1909 Mallory Lane, Suite 308Franklin, TN 37067251 Hillcrest Drive, Suite 101Clarksville, TN 37043HAROLD F. MOESSNER, M.D.JOSEPH T. BELLEAU, M.D.PATIENT INFORMATION:DATE:NAME:MALELastFirstFEMALEMiddle NE: HOMEWORK:EMPLOYER (or school):GRADE:S.S.#PRIMARY HEALTH CARE DOCTOR:SPOUSE/PARENT/GUARDIAN:PERSON RESPONSIBLE FOR ACCOUNT:NAME:RELATIONSHIP: (check one)SS#BIRTHDATE:MOM DAD GUARDIAN SPOUSE SELFTELEPHONE: HOME WORK:ADDRESS:EMPLOYER:INSURANCE:POLICY ID#:GROUP #:EMERGENCY CONTACT:TELEPHONE:(outside of immediate family)HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE? YES NOWHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?AGREEMENT: As a courtesy, we file insurance provided the patient furnished all information necessary. I understand that the portion of my treatment not covered byinsurance is due and payable at each visit. I also understand that my insurance is a contract between me and the insurance carrier, and not between the insurance carrier andthe doctor, and that I am still responsible for all fees. If my insurance company has not paid their portion within 60 days of being properly billed, I understand that thebalance will become due and payable from me. If I do not pay the entire amount due on my statement within 60 days of the date of service, a late charge may be added tomy account for the current monthly billing period. The late charge will be periodic rate of 1.75% per month (or a minimum of 1.00 for all balance under 57.00) which isan annual percentage rate of 21%. Customer, Patient, Borrower, etc. agrees to pay all cost of collection including attorney fees, collection fees, and contingent fees tocollection agencies of not less than 35%, such contingency fee to be added and collected by the collection agency immediately upon your default and our referral of youraccount to said collection agency.CONSENT: I have read the above information and give my permission to the office of Cool Springs Allergy Associates, P.C./Clarksville Allergy Clinic to utilize diagnosticaids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s medical needs and to file my insurance claims and if need to be forward my medicalrecords to my insurance company if they so require to process any claim on my behalf. This agreement gives Cool Springs Allergy Associates, P.C./Clarksville AllergyClinic authorization to release necessary information to my pharmacy for new prescriptions or refills to be called in by phone, to contact my home, work place, or any othertelephone number I deemed appropriate. Messages may be left on my answering machine or with family members.*** IF YOU ARE UNABLE TO KEEP YOUR APPOINTMENT, PLEASE LET US KNOW 24 HOURS IN ADVANCE ***SIGNATURE:DATE:WITNESS:
COOL SPRINGS ALLERGY ASSOCIATES / CLARKSVILLE ALLERGY CLINICHAROLD F. MOESSNER, M. D.JOSEPH T. BELLEAU, M.D.(615) 771-8800PATIENT’S NAMELastFirstMiddleADDRESSTELEPHONESOCIAL SECURITY #DATE OF BIRTHMarital Status: q Marriedq Singleq Divorcedq WidowedREFERRING PHYSICIANCHIEF COMPLAINT (Please decribe your symptoms in the space provided below)FOR OFFICE USE ONLYDATE:ALLERGY HISTORY:CHECK THE SYMPTOMS THATPROMPTED YOUR VISITReferred by:NOSE & HEAD:CHEST:Itchy NoseWheezeSneezingShortness ofChief Complaint:History of Present Illness:BreathStuffy NoseTight ChestRunny NoseSmotheringPost NasalChest InfectionDrainageSore ThroatCoughingHoarsenessSKIN:Loss of VoiceHivesHeadacheEczemaSinus InfectionsItchingItchy EyesSwellingRed EyesWatery EyesEye SwellingINSECT STING:Itching EarsLife-ThreateningBlocked EarsReactionApproximately how many years have youhad your symptoms:a) Head and noseyearsb) Chestyearsc) SkinyearsPage 1
FOR OFFICE USE ONLYProblems:SeasonalYear roundDo you have increased symptoms fromany of the following?A) ALLERGENSq Mowed grassq House dustq Catsq Dogsq Moldq Musty placesq Dead leavesq Hayq PollensB) IRRITANTSq Smokeq Outside dustq Odorsq Perfumesq Paintq Fumesq Hair sprayq Soapsq Detergentsq Yes q Noq OccasionalLocation (frontal, top, back, cheeks, temples)or othersFrequency (times per week or month)Duration (minutes, hours, days)Character (throbbing, sharp, dull)Relief (e.g., medications, sleep, etc.)HEADACHES:Aggravating Factors (stress, infection, etc.)REVIEW OF SYSTEMS:CONSTITUTIONAL SYMPTOMS: fever, weight loss/gainCNS: headaches, dizziness, numbness, faintingFOODSFood allergies with description of reaction:OPH: blurred vision, double vision, photophobiaENT: puritic nose, nasal congestion, PNDPULMONARY: SOB, wheeze, chest tightnessCARDIAC: chest pains, palpatations, irregular heart beatPREVIOUS ALLERGY EVALUATIONGI: nausea, vomiting, constipation, diarrheaHave you seen an allergist before q Yes q NoENDOCRINE: polyuria, polydypsia, temp instabilityIf so, when?Do you have skin test results? q Yes q No HEM/ONC/LYMPH: bleeding, swelling, bruising(If so, please bring skin test results to our office)Have you ever been on allergy shots? q Yes q NoIf so, are you still taking them? q Yes q NoIf not, Approximately how long did you takethem?When did you quit?Your last Chest X-ray: Last Sinus X-ray:When?When?Why?Why?Results?Results?Ordered by:Ordered by:Dr.Dr.INFECTIOUS: recurrent, difficult to treat, life threateningMUSCULOSKELETAL/RHEUMATOLOGIC: arthritis, muscle weaknessmyalgia, arthralgiaSKIN: puritis, rashes, boilsPSYCHIATRIC: depression, insomniaPatient:Page 2ENVIRONMENTAL SURVEY (please check all that apply)Any Pets q Yes q NoInside house? q Yes q No List Inside Pets:Do you smoke? q Yes q No If no, in past? q Yes q No Anyone else smoke inside the house? q Yes q NoAny mold problems in house? q Yes q NoType of heating? q Central q Radiant q Wood q Kerosene q Other:
PAST MEDICAL HISTORYList all hospitalizations and surgeries in order of most recent:CAUSE OF HOSPITALIZATIONYEAR1.4.2.5.3.6.YEARWhat other conditions are you being treated or followed for:Past medical conditions or injuries:If patient is a child, are immunizations up to date?Do you have a living will? q Yesq Yesq Noq NoMEDICATIONSPlease list all current medications you are taking to relieve your ALLERGY symptoms:1.4.2.5.3.6.Please list all OTHER medications you are taking regularly:1.4.2.5.3.6.List any medications you take OCCASIONALLY (e.g. Tylenol, sleeping pill, etc.):1.2.DRUG ALLERGIESPlease list all medications to which you are allergic:FAMILY HISTORY (Please check any that us ProblemsqqqImmune DeficiencyqqqEczemaqqqSOCIAL HISTORYEmployment/School: Where are you employed/or where do you go to school?MotherqqqqqChildrenqqqqqOthersqqqqqJob Description:Does anything at work bother your allergies?Number of days missed from work/school per year because of allergy, sinus, or asthma problems?If patient is a child, does he/she attend day care? q Yesq NoHow many people are living at home?Recreation: Please list your favorite hobbies:Patient:Reviewed and discussedDoctor Signature:Date:PAGE 3
IDENTIFICATION OF PERSONAL REPRESENTATIVEName of patientDOB / /I hereby grant the individual named below access to my protected health information. This individualmay receive and act upon information received from COOL SPRINGS ALLERGY ASSOCIATES, P.C./CLARKSVILLE ALLERGY CLINIC. This information may include clinical information about my care, aswell as billing information related to my insurance coverage and payment activity for services renderedby COOL SPRINGS ALLERGY ASSOCIATES, P.C./CLARKSVILLE ALLERGY CLINIC. I understand I may revoke this authorization at any time.I understand that I have the right to review the information being disclosed to my personalrepresentative.I also understand that the protected health information released to my personal representativemay be further disclosed by the recipient. COOL SPRINGS ALLERGY ASSOCIATES, P.C./CLARKSVILLE ALLERGY CLINIC cannot guarantee the further safeguarding of the healthinformation after the disclosure.I acknowledge that I have received a copy of COOL SPRINGS ALLERGY ASSOCIATES, P.C./CLARKSVILLE ALLERGY CLINIC (Dr. Harold F. Moessner, M.D. and Dr. Joseph T. Belleau, M.D.)privacy practice notice regarding privacy of personal health information. Patient signature Date signed / /Personal representative DOB / /Daytime PhonePersonal representative DOB / /Daytime PhonePersonal representative DOB / /Daytime PhonePersonal representative DOB / /Daytime PhoneRequests may be mailed to the following address:1909 MALLORY LANE, SUITE 308FRANKLIN, TN 37067OR251 HILLCREST DRIVESUITE 101CLARKSVILLE, TN 37043
COOL SPRINGS ALLERGY ASSOCIATES, P.C. / CLARKSVILLE ALLERGY CLINIC 1909 Mallory Lane, Suite 308 251 Hillcrest Drive, Suite 101 Franklin, TN 37067 Clarksville, TN 37043 HAROLD F. MOESSNER, M.D. JOSEPH T. BELLEAU, M.D. PATIENT INFORMATION: DATE: NAME: MALE FEMALE Last First Middle Initial
