Brookings Health System

REGISTRATION FORM
Todays Date: 12/1/2002

PCP: [PCP]
PATIENT INFORMATION

Patients last name: Simon

Is this your legal name?

First: Jim

Middle: F

Mr.

Marital status: Married

If not, what is your legal name?

Former name:

Birth date:

Age:

[Legal Name]

[Former Name]

2/11/1962

52

Sex:

Address: 47191 198th St Brookings, SD 57006

Social Security no.:

Home phone no.:

Cell phone no.:

555-66-0000

(605)692-1011

(605)695-9123

Occupation:

Employer:

Employer phone no.:

Carpenter

Bills Construction

(605)692-2580
[Doctors name]

Chose clinic because/referred to clinic by (Please choose one option):

Friend
Other family members seen here: [Other patients]
INSURANCE INFORMATION
(Please give your insurance card to the receptionist.)
Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

Jim Simon

2/11/1962

[Address]

(605)692-1011

Is this person a patient here?

Occupation:
Carpenter

Is this patient covered by insurance?

Employer:
Bills Construction

Employer address:

Employer phone no.:

th

301 7 Ave S Brookings SD, 57006

(605)692-2580

Please indicate primary insurance: Insurance 1 | Other:

Subscribers name:

Subscribers S.S. no.:

Birth date:

Group no.:

Policy no.:

Co-payment:

Joe Simon

555-66-7777

2/11/1962

[Group #]

[Policy #]

$35

Patients relationship to subscriber: Self | Other:

Name of secondary insurance (if applicable):

Subscribers name:

Group no.:

Policy no.:

[Secondary Insurance]

[Name]

[Group #]

[Policy #]

Patients relationship to subscriber: [Choose an item] | Other: [Relationship to subscriber]

IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):

Relationship to patient:

Home phone no.:

Work phone no.:

Bill Halloway

Friend

(605) 692-9901

(605)692-2580

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially
responsible for any balance. I also authorize Brookings Health System or insurance company to release any information required to process my claims.

Patient/Guardian signature

Date

PATIENT NAME: Jim Simon

5/21/02

Weight: 175
Blood Pressure: 123/82
Temperature: 98.9
Medications currently taking: none
Symptoms: Itchy eyes, runny nose, difficulty breathing
Notes:
Medications: Over the counter allergy meds
Return in:

7/13/02

Weight: 176
Blood Pressure: 120/82
Temperature: 98.6
Medications currently taking: Benadryl
Symptoms: Itchy eyes, runny nose, and difficulty breathing
Notes: Symptoms have not gotten better, working outside all of the time due to his job, said he changes clothes immediately when he gets
home
Medications: switch to Claritin D
Return in: 1 month if not better

8/12/02

Weight: 175
Blood Pressure: 122/81
Temperature: 98.7
Medications currently taking: Claritin D
Symptoms: Itchy eyes, runny nose/congested, and difficulty breathing
Notes: Symptoms have not gotten better, in fact they seem to have gotten worse, possibly due to the increase of allergens in the air, has been
running the air conditioner along with changing clothes immediately still
Medications: trying Allegra, if it does not help, we will try giving the shots
Return in: 2 months

10/22/02

Weight: 173
Blood Pressure: 122/84
Temperature: 98.7
Medications currently taking: Allegra
Symptoms: Itchy eyes, runny nose/congested, and difficulty breathing
Notes: Allegra helped a little but still not feeling 100%, the allergy season is dying down so we will continue with Allegra, but if symptoms
reoccur next summer, come back and we will start with the shots
Medications: Allegra until the ground freezes and allergens die
Return in: if symptoms reoccur in the summer of 03

5/20/03

Weight:175
Blood Pressure:124/82
Temperature:98.6
Medications currently taking: Allegra
Symptoms: Itchy eyes, runny nose
Notes: Symptoms came back with the new summer season, we will try the shots now
Medications: immunotherapy
Return in:

[Date]

Weight:
Blood Pressure:
Temperature:
Medications currently taking:
Symptoms:
Notes:

Medications:
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[Date]

Weight:
Blood Pressure:
Temperature:
Medications currently taking:
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Notes:
Medications:
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10 questions and answers for the interview:

1. When did you start noticing that you had symptoms of seasonal allergies (how old)?
a. Late 20s
2. Did you ever think it was just the common cold?
a. No, there were more things than just the common cold. There were itchy eyes and
runny nose. Nothing common with a cold.
3. How have you taken care of your allergies?
a. For the most part, over the counter medicines.
4. Do prescriptions help more or over the counter drugs?
a. In recent years, over the counter but prescriptions are always stronger
5. What prescription drugs have you taken?
a. Claritin which used to be prescription
b. Recently a shot, I dont remember the name
6. What are some side effects from taking the medications?
a. Dry throat
7. How much does it cost per year to buy medications for your seasonal allergies?
a. About $150
8. What symptoms do you have now?
a. Itchy eyes, stuffy head, sinuses stuffed up
9. Which is the worst symptom?
a. Sinus stuffiness because it also causes headaches
10.Are your allergies worse in the spring or fall? And why
a. Usually fall, certain allergens that come out in the fall of the year. Probably ragweed
mostly
11.How do you avoid having allergens get into your home?
a. Keep windows closed and run the air conditioner
12.Do any of your siblings have seasonal allergies? Who?
a. Yes, Janice had them, Mike has them, Patty has them somewhat
13.Are their symptoms the same as yours? Are there any different ones that they have that
you dont have?
a. Similar, and they dont have any other different ones