What is the reason for coming to our practice? *
Year / Where?
DATE OF 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: *
What has not helped?
What provides most relief?
Drug Allergies: *
Reactions (to drug allergies listed above): *
If so, how many times in the last 12 months?
What hospital?
Were you admitted? Yes / No. If so, date of admission:
Surgeries: *
Allergies/Hay Fever (Family History - Relationship & Paternal/Maternal): *
Atopic Dermatitis (Family History): *
Asthma (Family History): *
Food Allergy (Family History): *
Penicillin Allergy (Family History): *
Sinusitis (Family History): *
Other (Family History): *
Please tell us how many of each animal you have "Only leave this section blank if you DO NOT HAVE ANY ANIMALS":
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 (prescription, over-the-counter, vitamins, supplements): *
Are you currently taking antihistamines? If yes, what kind? *
If yes to Pneumonia Shot, what date?
Please list any other helpful information:
First Name: *
Middle Initial:
Last Name: *
Street Address: *
Street Address Line 2:
City: *
State / Province: *
Postal / Zip Code: *
Email: *
Date of Birth: *
Social Security Number:
Marital Status: *
Employer: *
Job Title: *
If Patient IS A MINOR, PROVIDE MOTHER AND FATHERS FIRST AND LAST NAMES:
Mother's First and Last Name:
Father's First and Last Name:
Emergency Contact Name: *
Relationship to Patient: *
Emergency Contact Street Address: *
Emergency Contact Street Address Line 2:
Emergency Contact City: *
Emergency Contact State / Province: *
Emergency Contact Postal / Zip Code: *
Pharmacy: *
Pharmacy City: *
PRIMARY INSURANCE CARRIER: *
ID#: *
GROUP#: *
Policy Holder's Name: *
Policy Holder's DOB: *
Policy Holder Street Address: *
Policy Holder Street Address Line 2:
Policy Holder City: *
Policy Holder State / Province: *
Policy Holder Postal / Zip Code: *
SECONDARY INSURANCE CARRIER:
Secondary ID#:
Secondary Policy Holder's Name:
Secondary Policy Holder's DOB:
Secondary Relationship to Patient:
Secondary Policy Holder Street Address:
Secondary Policy Holder Street Address Line 2:
Secondary Policy Holder City:
Secondary Policy Holder State / Province:
Secondary Policy Holder Postal / Zip Code:
PRIMARY CARE PHYSICIAN: *
PCP Street Address: *
PCP Street Address Line 2:
PCP City: *
PCP State / Province: *
PCP Postal / Zip Code: *
REFERRING PHYSICIAN: *
By submitting this form, I confirm that the information provided is accurate and complete. *
Today's Date: *