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 *

Month Day Year
Birth Date *

Month Day Year
Patient Name *
Social Security Number
Address *

Street Address

Street Address Line 2

City State / Province

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

Male Female
Marital Status *

Single Married Widowed Separated Other
Patient Employed By *
Work Phone *
Employer Address *

Street Address Line 2
Occupation *
Responsible Party (If Minor) *
Birth Date *

Month Day Year
Is the responsible party's address different?

Yes No
Address

Street Address

Street Address Line 2

City State / Province

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

Yes No
If yes: Name of Primary Insurance: *
Card Holder ID/Contract # *
Group # *
Card Holder Name *
Date of Birth *

Month Day Year
Card Holder Employer *
Do you have secondary medical insurance? *

Yes No
Name of Secondary Insurance *
Card Holder ID/Contract # *
Group # *
Card Holder Name *
Date of Birth *

Month Day Year
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 *

Month Day Year
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

Month Day Year
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

Month Day Year
ALLERGY / ASTHMA QUESTIONNAIRE
DATE *

Month Day Year
NAME *
D.O.B: *

Month Day Year
AGE *
Are you taking any medications on a regular basis? (Including Vitamins / Inhalers) *

No Yes (if yes fill out medicine sheet including drug allergies)
Medication Sheet
DRUG ALLERGIES (include reaction and date): *

Street Address Line 2
Name: *

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

Yes No
Where? *
When? *
Associated symptoms

Sneezing Itching Hives Swelling Stuffy nose Runny nose Rash Short of breath Wheezing Cough Other
Has anything helped the condition?
Which seasons, if any, are your symptoms worse?
Select any of the below which make your symptoms worse:

Exercise Smoke Cold Air Foods Dust Irritants Mold Stress Pets Cosmetics Colds/Flu Emotion Cut Grass Chemicals Humidity Weather Change Being Outdoors Being Indoors Night Morning
Symptoms you are currently having
Heart *

Chest Pain Dizziness Palpitations NONE
Lungs *

Breathing Difficulty Problem with breathing w/exercise Chest Tightness Shortness of breath Wheeze Cough Nocturnal symptoms NONE
Nose *

Bleeding Congestion Dry Mouth Mouth Breathing Nasal Speech Runny Loss of Taste or Smell Snoring Sneezing NONE
Eyes *

Dark Circles Contacts Glasses Itchy Red Runny Swollen NONE
Ears *

Itchy Pain Plugged Popping Ringing NONE
Throat *

Scratchy Pain Post Nasal Drip Throat Clearing Voice Change Trouble Swallowing NONE
Skin *

Swelling Dry Flushing Itching Hives Rash NONE
Constitutional *

Loss of Appetite Fatigue Fever Poor Sleep Weight Gain Weight Loss NONE
Gastro Intestinal *

Constipation Diarrhea Nausea Abdominal Pain Reflux Vomiting NONE
Muskoskeletal *

Swelling NONE Pain
Sinus *

Headache Face Pain TMJ Pressure Teeth Pain NONE
Neuro/Psych *

Anxiety Depression NONE
Other
Allergy History
Have you been tested for allergies before? *

Yes No
If yes: By whom? *
When? *
How were you tested? *
Have you ever received allergy injections? *

Yes No
Year Started: *
Date of last injection: *
Any adverse reactions?
Have you had an adverse reaction to contrast dye? *

Yes No
Have you had an adverse reaction to latex? *

Yes No
Are symptoms caused or made worse by foods? *

Yes No
Which ones? *
Have you ever had a severe reaction to an insect sting? *

Yes No
What insect? *
Have you ever had a rash after coming into physical contact with something: *

Yes No
What was it you were coming into physical contact with? *
Have you had any pulmonary testing in the past year? *

Yes No
By whom? *
Have you had a chest x-ray in the past year? *

Yes No
By whom? *
Have you had a sinus x-ray in the past year? *

Yes No
By whom? *
Past Medical History *

Asthma COPD Eczema High Blood Pressure Heart Disease Migraine Diabetes Reflux Depression Anxiety ADD Thyroid Disease Recurrent Infections None of the above
Other
Surgeries:
Is the patient under the age of 12? *

Yes No
Birth History

Natural Caesarean
Induced:

Yes No
Birth Weight
How many weeks pregnant at delivery?
Any Complications?:

Yes No
Did the patient require oxygen at birth?:

Yes No
If yes, how long?
Was the patient intubated(on a ventilator)?

Yes No
If yes, how long?
Was newborn taken home on time?:

Yes No
If in NICU, for how long?
Social History:
School grade or occupation: *
Day Care (if child)

Yes No
Marital Status *

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

Yes No
How long
Year Quit

Month Day Year
Have you ever smoked? *

Yes No
How much?
How long
Year Quit

Month Day Year
Do you drink alcohol? *

Yes No
Amount per week *
How much caffeine do you drink in a day? *
Recreational drugs use? *

Yes No
Frequency and which drugs: *
Traveled in the past six months prior to the onset of symptoms? *

Yes No
Where to? *
Hobbies/leisure activities: *
Who else live in the home? *
Family Medical History:
Any family history of asthma, allergies or eczema?

Yes No
Father: *

Living Deceased
Age: *
Medical problems: *
Mother: *

Living Deceased
Age: *
Medical problems: *
Brothers/Sisters:

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

Yes No
Are you exposed to second hand smoke? *

Yes No
If yes, is exposure at *

Home Work
other *
Does school or your job cause or worsen your condition? *

Yes No
Any exposure to chemicals or fumes? *
Dwelling
What is the primary residence?

House Apartment Mobile Farm
Other
Primary Residence
Is dwelling? *

Damp Dusty Neither
When did you move in? *
When was it built? *
Basement? *

Yes No
If, Yes *

Damp Dry
Carpet in home? *

Yes No
Wood Burning Stove? *

Yes No
Central Air? *

Yes No
Pillows: *

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

Yes No
What kind of pets and how many?
Do you have a secondary residence?

Yes No
House Apartment Mobile Farm
Is dwelling?

Damp Dusty
When did you move in?
When was it built?
Basement?

Yes No
If,Yes

Damp Dry
Carpet in home?

Yes No
Wood Burning Stove?

Yes No
Central Air ?

Yes No
Pillows:

Polyester Feather
Pillow Age:
Mattress age:
Do you have any pets?

Yes No
What kind of pets and how many?

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Registration Form

ALLERGY / ASTHMA QUESTIONNAIRE

Medication Sheet

Symptoms you are currently having

Allergy History

Social History:

Family Medical History:

Environmental:

Dwelling

Primary Residence

HIPPA