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Allergy Questionaire

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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.

​​​​​​​I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.

I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.

By selecting  below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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What is your height?
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What is your weight in pounds
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To ensure your provider can safely evaluate your symptoms, we’ll ask a few questions about your health history, medications, and allergies.
Please identify all your current medical conditions
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Please list all your current medications including dosages.
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Please list all of your known allergies.
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Medical History

Within the last week, have you experienced any of the following? (Select all that apply)
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Medical History

Which of the following asthma symptoms are you currently experiencing? (Select all that apply)
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Medical History

How would you describe your symptoms?
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Medical History

How many days per month does your asthma interfere with your sleep?
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Medical History

How much does your asthma interfere with your normal daily life?
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Medical History

Have you experienced any of the following in the past four weeks? (Select all that apply)
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Medical History

If you use an albuterol inhaler, how often do you use it?
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Medical History

What inhaled medication have you used?
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Medical History

Have you ever experienced or been diagnosed with any of the following? (Select all that apply)
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Medical History

Is your GERD well-controlled?
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Medical History

Do you have or have you ever had any of the following? (Select all that apply)
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What other information or questions do you have for the doctor?
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Indication for Use:


You are requesting treatment for asthma with one or more medications that may include inhaled corticosteroids, bronchodilators, or combination therapies. Commonly prescribed inhalers and medications for asthma management include (but are not limited to):

  • Proair (albuterol)
  • Wixela (fluticasone propionate/salmeterol)
  • Advair (fluticasone propionate/salmeterol)
  • Fluticasone-Salmeterol (combination inhaled corticosteroid and long-acting beta-agonist)
  • Levalbuterol (a short-acting beta-agonist)
  • Other similar agent
 

    These medications help control and prevent asthma symptoms by reducing inflammation in the airways, relaxing bronchial muscles, and improving airflow.

    Potential Benefits:

    • Improved respiratory function
    • Reduction in the frequency and severity of asthma attacks
    • Enhanced quality of life and ability to perform daily activities
    • Better overall lung function

     
      Potential Side Effects:

      While these medications are generally safe and effective, they can cause side effects. Although serious side effects are not common, they can occur. Common and serious side effects include, but are not limited to:

      Common Side Effects:


      • Throat irritation or hoarseness
      • Oral thrush (yeast infection)
      • Cough
      • Dry mouth
       
        Serious Side Effects:

        • Paradoxical bronchospasm (worsening of breathing difficulties)
        • Severe allergic reactions (e.g., rash, swelling, difficulty breathing)
        • Systemic effects from long-term use of inhaled corticosteroids (e.g., decreased bone density, cataracts, or adrenal suppression)
        • Elevated heart rate or palpitations (particularly with bronchodilator use)
         
          Risks and Considerations:

          • Inhaler Technique: Proper inhaler technique is critical for the medication to be effective. Incorrect use may lead to reduced medication delivery and inadequate control of asthma symptoms.
          • Worsening Symptoms: If you experience worsening breathing difficulties or new symptoms, contact your healthcare provider promptly.
          • Allergic Reactions: Seek immediate medical attention if you experience severe allergic reactions, such as hives, swelling of the face/tongue, or difficulty breathing.
          • Long-Term Use: Prolonged use of inhaled corticosteroids can sometimes lead to systemic effects; regular check-ups can help minimize these risks.

           
            Monitoring and Follow-up:

            • You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. These visits may include lung function tests and reviews of your inhaler technique to ensure optimal treatment outcomes.

              Consent : I acknowledge the potential benefits, risks, and side effects of the above-listed medications and any other asthma medications that may be prescribed. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of these medications as part of my treatment plan for asthma.
               
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              Please attest to the following confirming that all information you have provided to us is true and complete.

              I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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              Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

              What you were seeking help for:

              • Asthma

              Why this happens

              Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
              Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

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