New Patient Form
Date of Birth
Allergy Review of Symptoms: (Please check all that apply)
Post Nasal Drip
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
Allergy Triggers: (Indicate where/when symptoms occur.)
In Damp Areas
Food Allergy Triggers (List any suspected or known triggers.)
Current Medications (All medications, including allergy medications and over the counter.)
Are you currently pregnant?
Do allergy medications help relieve your symptoms?
Have you ever had an anaphylactic reaction?
Have you been allergy tested within the past year?
Have you ever had allergy shots or taken allergy drops?
Are you currently taking any beta blockers?
Are you currently being treated for asthma?
In the past year have you required an oral steroid for asthma?
Are you currently taking medications for asthma?
(If Yes) What medications are you currently taking for asthma?
Do you use a rescue inhaler?
(If Yes) How often do you use the rescue inhaler?
Do you use a peak flow meter?
(If Yes) What is your typical peak flow (liter/min)?
Attach allergy test if available.
I agree that the information provided on this form is correct and accurate to the best of my abilities.