PCAAC Patient Full History and Examination Form
Praana Charitable Allergy Asthma Clinic (PCAAC)  -- All locations.
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Date and Time of Appointment
Select the PCAAC volunteer physician. *
This form is being completed by:
Patient ID
Patient's  Full Name
First name Middle initial Last name. Example: Pudupakkam K. Vedanthan
Patient Phone Number
Patient's Sex
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Patient's Current Age (in years).
Patient's Occupation
Type of Appointment
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Patient's Chief Complaints:
Present History: EENT
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Present History: CHEST
Select all that apply.
Present Problems: SKIN (Rashes)
Doctor: Please describe the following: 1. Date of onset; 2. Progress; 3. Seasonality; 4. Precipitants; and 5. Treatment plan.
Progression of Symptoms *
Past History:
Any known allergies?
Family History
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Personal Habits:
Environmental History
Select all that apply.
PE: SKIN
PE: ENT
PE: LUNG
Add any additional comments below.
Allergy Skin Testing:
Positive
Negative
Saline Control
Dust Mite
Alternaria
Cockroach
Prosopis
Sorghum
Parthenium
Dog
Cat
Histamine Control
PEFR Readings
Please provide 3 readings of the patient.
Spirometry: Interpretation
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Diagnosis
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Treatment Plan
Follow-Up Visit Details
Specify approximate date and time of follow up visit.
MM
/
DD
/
YYYY
Time
:
Doctor's Signature (please type).
Submit
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