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Muncie Allergy Center, P.S.C.
Sai Karlapudi, M.D.
Jordan Overholt, F.N.P.
4505 North Wheeling Avenue Muncie, Indiana 47304
Phone (765) 284-4050 Fax (765) 284-9301
New Castle Clinic 1007 N 16th Street 47362
www.muncieallergycenter.com
Dear Patient, ________________________________ has an appointment _____________________________________ Thank you for choosing Muncie Allergy Center for your care. Please call us to confirm your appointment at 765.284.4050 when you receive this packet. Our office requires a 24-hour cancellation
and in the event that we do not receive this notice, there will be a $25.00 fee.
Please fill out the patient history form and bring this packet along with any insurance cards to the office the day
of your appointment and be prepared to pay any co-pay required by your insurance.
Please bring a list of all medications that you are currently taking and records of previous treatments
including written x-ray reports, lab, skin tests, or blood test results. Many times if you call your family
doctor and ask, s/he will send a letter describing your treatment along with pertinent medical records.
Your primary care physician’s office can provide a Release of Information form which can be sent to
other physicians or hospitals prior to your appointment.
If you will be seeing us in regard to nasal allergies, sinus trouble, and/or asthma, we may need to do allergy skin
testing, which means you should not take antihistamines for 5 days prior to the scheduled appointment. Many
over the counter medications that say “allergy” contain antihistamines. If in doubt ask your pharmacist.
Antihistamines that will need to be stopped 5 days prior to your appointment are Allegra (fexodendaine),
Allegra D, Claritin (loratadine), Claritin D, Clarinex, Clarinex D, Zyrtec, Zyrtec D, .Xyzal pills & Astelin,
Astepro, Patanase nasal Sprays. If you are taking blood pressure medicine, call before your appointment to
speak with a nurse. Most other medications, including asthma medications, will not interfere with skin testing
and should be continued. If you have a skin rash or hives, it is not necessary to stop your medication for the first
visit. Please call us at 284.4050 with any questions.
Our office is located 8/10ths of a mile North of McGalliard Road on the West side of Wheeling Avenue
and 2/10ths of a mile South of Riggin Road.
You are scheduled for a 2-hour appointment. Please plan on being here the full time if necessary. If the patient
is a young child, it is helpful to bring along favorite toys or even a second adult to keep the child occupied for
this length of time.
Thank you for your cooperation as we are making every effort to see you in a timely manner. Please visit our
website listed above for directions to our Muncie and New Castle locations.
Sincerely,
Sai Karlapudi, M.D.
Jordan Overholt, F.N.P.
Please answer the following questions about yourself or your child: What is the main reason you are here today?
How long have symptoms been present?
The following list includes s list of symptoms. For the symptoms indicate whether they are (1)mild , (2)moderate, or (3) severe
1, 2, 3
CHEST SYMPTOMS
THROAT OR SINUSES
wheezing or coughing worse with exercise? have you ever had bronchitis, pneumonia, or how many times have you been hospitalized NASAL SYMPTOMS
HEADACHES

How frequent are the headaches? _______________________________________________
Any other family members with headaches? _______________________________________
Are there certain times of the year or types of weather when your symptoms are worse? ________
When? ____________________________________________________________________
What other activities or exposures (hobbies, work, strong odors, etc.) can you think of that make your
symptoms worse? __________________________________________________________________
Have your symptoms been helped by any medications you have tried in the past? ________________
About how many days of work or school per year do you miss from the above symptoms? _________
Have you had an adverse reaction to an insect sting and were you prescribed medications for it?
Please list below.
_____________________________________________________________________________________
Have you had any allergic reactions or any type of bad reactions to medications? If so, describe. _______
_____________________________________________________________________________________
Are these any foods which cause you to have rashes, cramps, swelling, or asthma? If so, describe. ______
_____________________________________________________________________________________
Do you now, or did you ever smoke? _______ If yes, what and how much per day? __________________
Have you stopped smoking? ___________
How many years have you smoked? _________
Are you exposed to tobacco smoke at home or at work? _________

Please list all present medications.

Please include dosage, strength, and number of times a day taken. Please also include over-the-counter
medications including aspirin or other pain medications, laxatives, or vitamins. ___________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
How many times have you taken antibiotics in the past year? ______ Can you recall the names of any of the
antibiotics? ___________________________________________________________________________
Have you ever received cortisone or steroids in injection or tablet form? If so, how frequently? _________
_____________________________________________________________________________________
Please list all previous surgical procedures, serious accidents, or injuries with approximate dates. ________
______________________________________________________________________________________
Please list any other hospitalizations (including childbirth) and the medical diagnosis and treatments with
approximate dates. _____________________________________________________________________
_____________________________________________________________________________________
Are you under a doctor’s care for any other medical conditions? (blood pressure, diabetes, etc.) ________
_____________________________________________________________________________________
REVIEW OF SYSTEMS:
Do you now have or have you had difficulties with any of the following?
______Swelling of feet or ankles (edema) IF YOU HAVE ANY BLOOD RELATIVES WITH THE FOLLOWING PROBLEMS. PLEASE CHECK THE APPROPRIATE COLUMN. Asthma Do any blood relatives have: _______Diabetes PREVIOUS ALLERGY EVALUATIONS
Have you ever had an allergy evaluation in the past?_______ If yes, at what age was the allergy evaluation
done? _________.
Circle the diagnosis that was made: Hayfever Asthma Eczema Sinus Other
If you were skin tested, to what were you found to be allergic?
Trees Grass Weeds Molds Dust Animals Feather Foods Other
Have you received allergy injections in the past?_________
What improvements have you noticed? ___________________________________________________
COMPLETE THE FOLLOWING QUESTIONS FOR CHILDREN UNDER EIGHT
Any breathing problems or other complications in the nursery?_________________________________
Please explain________________________________________________________________________
Breast fed? ________ How long? ________ Bottle fed? ________ Type of formula? _________
Any difficulties with formula? _______________________________________
DURING THE FIRST YEAR OF LIFE DID THE CHILD HAVE:
_______ Skin rash (other than diaper rash)
ENVIRONMENTAL HISTORY
Please circle appropriate answers or fill in the blanks.
Neighborhood: urban suburban rural cultivated fields woods near water
House
Apartment
Mobile Home

Time living there________ approximate age of dwelling ________
Basement:

Crawl Space: damp
forced air gas electric oil gas stove radiant heat
Air Conditioning:

Humidifier
Dehumidifier

Use of: potpourri

Pets: Dog #________
Others: Including exposure to farm animals ____________________________
Bedroom:

Employment History:
Present type of employment _________________________________ Exposure to smoke, fumes, or other hazards _______________________________________ Daycare History (for children): Age when daycare started _________ number of other children at facility ________. PLEASE DO NOT WRITE ON THIS PAGE
Date ___________
PHYSICAL EXAMINATION
NAME _____________________ Ht _________ Wt ________ BP _________ PEFR _________
Eyes: Conjunctivae OK injected cobblestones lids puffy dark circles
Ears: Rt TM OK injected dull scarred amber fluid

Lt TM OK injected dull scarred amber fluid

Nose: No abnormality
septum deviated straight
no mucus scant clear white yellow thick bloody
polyps Rt Lt excoriations
membranes normal pink red pale lavender
edema none slight 2+ 3+ 4+
absent or small
enlarged
inflamed
posterior pharynx
inflamed
lymphoid hypertrophy
postnasal drainage none clear thin
yellow/green thick

Cervical glands:
unremarkable shotty
small nontender enlarged tender

Thyroid:
unremarkable
palpable

Chest:
Abdomen:
Musculoskeletal:
Skin:

Source: http://muncieallergycenter.com/forms/new_patient_packet_10_20_11.pdf