New Patient Medical History
PATIENT NAME
*
First Name
Middle Initial
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Today's Date
*
-
Month
-
Day
Year
Date
Who referred/suggested you visit us?
*
What is the reason for your visit today?
*
What Specific Symptoms are you having?
What Specific Symptoms are you having Continued?
Known Allergies: Environmental, Seasonal, Food, Medication, Bee Sting, Contact Dermatitis
Have you previously been tested for allergies?
*
Yes
No
Year / Where?
DATE ON ONSET: When you first started experiencing any of the above symptoms. If you do not know the specific date, please estimate an age or year of onset. Please provide DETAILS of the history of your problem: Has it varied over the years? Has it worsened or improved ?
*
Factors which affect your symptoms "Please select all that apply"
Spring
Summer
Fall
Winter
Seasonal Changes
Warm/Cold Air
Air Quality
Wind
Rain
Cut Grass
Leaf Raking
Environment (Work, School, Home)
Mold/Mildew
Smoke
Odors/Perfumes
Exercise
Certain Foods
Alcohol
Laughter
Viruses
Medications
Stress
Animals (Cat, Dog)
N/A
Other
What has not helped?
*
What provides most relief?
*
Patient's Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Past Medical History
Past Medical History Continued
Drug Allergies
*
Reactions
*
Have you recently been to the ER for Asthma?
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Yes
No
If so, how many times in the last 12 months?
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What hospital?
*
Were you admitted? Yes / No if so, date of admission
*
Surgeries
*
Tonsils out
*
Yes
No
Adenoids out
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Yes
No
Sinus Surgery
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Yes
No
Ear Tubes
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Yes
No
FAMILY HISTORY: PLEASE TYPE IN RELATIONSHIP TO YOU AND IF THEY ARE PATERNAL/MATERNAL
*
Home Environment
*
Is Patient in daycare/school setting?
*
Yes
No
Do you have animals? If yes please complete the next question
*
Yes
No
Please tell us how many of each animal you have "Only leave this section blank if you DO NOT HAVE ANY ANIMALS"
Smokers?
*
Yes
No
Former
If former smoker, when did you stop?
If yes, how many cigarettes
Do you use illicit drugs, if so what?
*
Please list all the medications you are currently taking
*
Are you currently taking antihistamines? If yes what kind?
*
Have you had Flu Shot this season
*
Yes
No
Have you had Pneumonia Shot
*
Yes
No
If yes what date?
*
Please list any other helpful information
Email
example@example.com
Submit
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