New Patient Form

First Name

Last Name

Date of Birth

Phone #

Email

Allergy Review of Symptoms: (Please check all that apply)

Sneezing Runny Nose Post Nasal Drip Nasal Congestion Hoarseness Scratch Throat Itchy Mouth Red/Watery Eyes Itch Eyes Itchy Ears Eczema Rash/Hives

Frequency/Time of Symptoms: (Please check all that apply)

Sporadic (At various times of the year but with no pattern.) Persistent (Throughout the year.) Seasonal (If seasonal, indicate the prominent months below)

(If Seasonal) Prominent Months

January February March April May June July August September October November December

Allergy Triggers: (Indicate where/when symptoms occur.)

After Mowing In Damp Areas Out Walking While Exercising Near Farms In Basement In Bed In Kitchen In Attic Around Cats Around Dogs Around Horses While Gardening

Food Allergy Triggers (List any suspected or known triggers.)

Current Medications (All medications, including allergy medications and over the counter.)

Are you currently pregnant?

Yes No

Do allergy medications help relieve your symptoms?

Yes No

Have you ever had an anaphylactic reaction?

Yes No

Have you been allergy tested within the past year?

Yes No

Have you ever had allergy shots or taken allergy drops?

Yes No

Are you currently taking any beta blockers?

Yes No

Are you currently being treated for asthma?

Yes No

In the past year have you required an oral steroid for asthma?

Yes No

Are you currently taking medications for asthma?

Yes No

(If Yes) What medications are you currently taking for asthma?

Do you use a rescue inhaler?

Yes No

(If Yes) How often do you use the rescue inhaler?

Do you use a peak flow meter?

Yes No

(If Yes) What is your typical peak flow (liter/min)?

Attach allergy test if available.

Terms Agreement

I agree that the information provided on this form is correct and accurate to the best of my abilities.