New Patient Secure Form

Thank you for your interest in our services. Please fill out the information below, and one of our team members will contact you to schedule an appointment time. We look forward to seeing you soon.
If you are interested in skin testing, please click here to view our Allergy Skin Testing Medication Information

PATIENT INFORMATION

* Patient: (Required)

* Gender: Male Female

* Birth Date:

Age:

* Address:

* City:

* State:

* Zip:

* Home Phone:

Work Phone:

Ext:

Cell Phone:

* E-mail:

Marital Status:

Student:

Spouse:

Spouse's DOB:

Social Security Number:

Driver's License Number:

Employer:

Status:

Years Employed:

Address:

Town:

State:

Zip:

PERSON RESPONSIBLE FOR ACCOUNT (If patient is a minor please complete next section)

Mother's Name:

Date of Birth:

Age:

Address:

City:

State:

Zip:

Employer:

Status:

Years Employed:

Social Security Number:

Father's Name:

Date of Birth:

Age:

Address:

City:

State:

Zip:

Employer:

Status:

Years Employed:

Social Security Number:

INSURANCE INFORMATION

* Primary Carrier:

* Insurance Company Phone Number:

* Policy Number:

Group Number:

* Sponsor/Employer:

* Referral?

Effective Date:

Secondary Carrier:

Insurance Company Phone Number:

Policy Number:

Group Number:

Sponsor/Employer:

Referral?

Effective Date:

IN CASE OF EMERGENCY, WHO SHOULD WE CONTACT?

* Name:

* Relationship:

* Phone (Home):

* (Cell):

WHO SHOULD WE THANK FOR THIS REFERRAL? NAME:

MEDICAL HISTORY

* Primary Care Physician:

Referred By:

Pharmacy Name:

Pharmacy Address:

Type?

* In your own words please describe your symptoms/problems you wish to be discussed today. Please include when it began, how often, when is it worse day/night, how long it lasts. What makes it better, what makes it worse? Do your symptoms interfere with your activities, are you ever symptom free?

* How many colds do you have each year? 1-2 3-5 6-12 More Than 12

Have you ever been evaluated by an Allergist?

If yes, name:

When:

* Have you ever had
Allery Skin Testing?

If yes,
when:

Have you ever received
Allery Injections?

How
Long?

Have you ever had Cortisone injections?

If yes, when and for what?

Has there been difficulty sleeping at night due to the symptoms of Allergy?

Please List ALL Medications (PRESCRIBED and OVER THE COUNTER) that you are taking at the present time and the reason for taking them - Include: Medication, Dosage, How much per day, Last Dose, and Reason for taking:

Do you have allergies to medications or food?

Last Eye Exam:

Doctor:

Last Physical Exam:

Doctor:

Last Dental Exam:

Dentist:

Last PAP Smear:

Last Mammogram:

First Date Last Menses:

Length/Flow:

Menopause:

Do you wear Latex Gloves Daily?

Do you use Latex Products Daily?

How many Surgeries have you had? Total:

Do you have Eczema or other Rashes on your hands?

If yes, explain:

Have you had itching, swelling, or other symptoms following dental, rectal or pelvic exams?

Have you experienced swelling or difficulty breathing after blowing up a balloon?

Do condoms, diaphragms, or Latex sexual aids cause itching or swelling?

Do rubber handles, rubber bands, or elastic bands on clothing cause any discomfort?

Marital Status:

Education Status:

Employer:

Occupation:

Occupational Exposure:

Recent Travel:

Hobbies (Indoor/Outdoor):

Do you smoke?

# per Day?

How long? (Years)

Have you considered quitting?

When did you quit?

Are you exposed to others smoking?

Estimated quit date?

Do you drink Alcoholic Beverages?

If yes, how many per week?

What type?

Do you get Congested?

Do you use illegal drugs?

If yes, please explain:

FAMILY HISTORY

Please provide the following: Living/Deceased, Age, Medical Conditions/Cause of Death

Mother:

Father:

Maternal Grandmother:

Paternal Grandmother:

Maternal Grandfather:

Paternal Grandfather:

Aunt/Uncle:

Sibling/Child:

ENVIRONMENTAL HISTORY

* Location of where you live:

* Do you live in a (style):

* Number of Floors:

* Age of Residence:

* Length of Occupancy (Months/Years):

* Heat:

* Air Conditioning:

* Humidifier:

* Basement:

* Air Filtration:

* Frequency Changed:

* Do you have pets?

If yes, describe:

* How many?

* How long exposed?

Are pets allowed in your bedroom?

What kind of pets have you had previously?

Flooring/Padding: Living Room?

Bedroom?

Basement?

Bedroom:

* How often do you change your bed linens?

* What water temperature are your linens washed in?

Allergy control Encasements on: Box spring Mattress Pillows Comforter

Have you had any new Environmental changes, books, trophies, stuffed animals, games, collections at: Home School Work

Past Surgeries:

Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

* Submitted by:

* Date: