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.
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