Language
English (US)
Spanish (Latin America)
New Patients
Patient's Full Name
*
First Name
Last Name
What is your Gender?
Male
Female
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Referring Doctor
What is your occupation?
Your Doctor
*
Balekian
Oren
Palumbo
Maciag
Schaefer
Yakaboski
Not Sure
Appointment Date
*
-
Month
-
Day
Year
Date
Appointment Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What is the reason for your visit? (e.g. Asthma, Nasal Allergies, Eczema, Food Allergies, Hives, Swelling and/or Symptoms)
*
Past Medical History
*
NONE
Asthma
Cancer
Cardiac disease
Diabetes
Heartburn/reflux
Hypertension
Psychiatric disorder
Thyroid disease
Autoimmune disease
Premature birth
Other
Are you Allergic to any medications? (if yes, please list)
*
No
Other
Current Medications
*
Does anyone in your family have a history of:
*
Asthma
Nasal allergies
Eczema
Food Allergies
Medication Allergies
Bee Sting Allergy
Other
Do you live in a:
House
Apartment
Duplex
Condo/Townhouse
Other
What type of flooring in your bedroom?
*
wall-to-wall carpeting
hardwood flooring
area rugs
Other
Any pets in the house?
*
Do you use or have history of using tobacco? Live with smoker? Select all that apply
No/Never
Yes - currently
Quit/Former
Smoker in house
Please sign to authorize us to access your medical records through CareEverywhere
Submit
Should be Empty: