Nasheds PA
New Patient Information
Present occupation (describe):________________________________Duration:_________________________
Past occupation (describe):___________________________________Duration:_________________________
Main problems now: ________________________________________________________________________
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Please give us more details about your problems
Breathing Problems/Asthma: How long do you have it?_________ Is it year round or seasonal?____________
Most recent episode:_________ How long it did last?________ Treatment used:________________________
Things bring it on/make it worse:______________________ Things make it better:_______________________
Is it the same, worse, or better since started? ________How often you get them per week or month? _______
How many of them are at night? _______ is it worse by day or by night? __________ How long the symptoms
last? ________ What do you feel? _________________________________________ Do you get wheezing
when you get the air in or out? __________________ How many ER visits or hospitalizations you had? ______
Your breathing medications: __________________________________________________________________
How often you use? The rescue medication per week: ________ the other medications per week: __________
Sinus Infections: How long do you have them? __________ How many infections per year? _______________
How long each last? _________ What was the treatment? ______________________ Did you have a sinus
CAT scan? ________ Did you had sinus surgery? _______ How many? ______ When was the last one?
__________ What are your symptoms when you have a sinus infection? _____________________
Nasal Congestion/Stuffy Nose: How long do you have it? _______ Is it year round or seasonal? ____________
is it daily or on/off? _______ How long it last when you have it? _________ Is it one side or both? __________
Things make it worse __________________________ Things make it better: ___________________________
is it the same, worse, or better since started? _________ What are your allergy medications: ______________
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Sneezing: How long do you have it? _______ Is it year round or seasonal? _________ How long it last? ______
Things bring it on: _____________________________Is it the same, worse, or better since started? ________
Cough: How long do you have it? ______Is it year round or seasonal? ______ How often do you cough? _____
Things make it worse: _________________________________ Things make it better: ____________________
Is it dry or wet? _______ Is it worse by day or by night? ______Is it the same, worse, or better since started?
_______ Do you cough with activities? ______ Your cough medications: _______________________________
Itchy and Watery eyes: How long do you have it? ____________ Is it year round or seasonal? _____________
How long it last? ________ Is it one side or both? ____________ Things make it worse: ___________________
Things make it better: _____________________________ Is it the same, worse, or better since started? _____
Your Eye medications: _______________________________________________________________________
Hives and Rash: How long do you have it? ______ Is it hives or rash? ______ Is it year round or seasonal? ____
How many times you had it? _______ How long it last? ______________ Where hives/rash started? ________
Where did it go from there? ______________________ Things make it worse:__________________________
Things make it better:____________________________ Do you have any pictures?__________ What it looks
like? __________________________________________ Is it the same, worse, or better since started? ______
Your rash or itching medications: _______________________________________________________________
Post Nasal Drip or Clearing the throat: How long do you have it?_________ Is it year round or seasonal?_____
How long it last when you have it? Minutes______ Hours_____ Days_______ Months_____ All the time_____
Things make it worse:___________________ Things make it better:__________________________________
is it the same, worse, or better since started?____________ Is it worse by day time or by night?____________
Does exercise affect it:________ Medications used for it:____________________________________________
Heart Burn: How long do you have it? ______ Is it year round or seasonal?______ How often you get it?_____
How long it last?__________ Where do you feel it?__________ Things make it better:____________________
Things make it worse:__________________________ Is it the same, worse, or better since started?_________
What other symptoms do you feel with it?_____________________ When is the worse time?______________
Snoring: How long do you have it?______ Do you have it every night?_________ Is it worse on one side?_____
Things make it worse :________________________ Is it the same, worse, or better since started:__________
Witnessed stop breathing at night?_______ Witnesses stop breathing duration:_________________________
How to you feel in the morning?_______________________________________________________________
Nose bleeds: How long do you have it? _____ Is it year round or seasonal? ________How long it last?_______
One side or both?_________________ Things make it worse:________________________________________
Things make it better:__________________________ Is it the same, worse, or better since started?_________
Have you had any trauma to your nose?____________ Do you have bleeding problem?___________________
Frequent Infections: How many colds/bronchitis/sinusitis/ear infections/other infections you get per year? __
How many years do you have them?_______ How long each last? _______How many pneumonia you had in
your life time? ________ How these infections were treated? _______________________________________
Please, bring with you any blood work results you have.
Headache: How long do you have it?______ Is it year round or seasonal?__________ How many times per
week/month? ____________ How long it last?____________ Where is the headache?___________________
Things make it worse:____________________________ Things make it better:__________________________
Is it the same, worse, or better since started?________ Have you had any trauma to your head?____________
Did you have CT of the head? ________Your headache medications:__________________________________
Ear Infections/Ear pain: How long do you have it? ____ Is it year round or seasonal:____________ How many
times per year?_____________ How long each last?_________ Is it the same, worse, or better since started?
__________Other symptoms you feel with it: ___________________________________________________
Bee Sting Allergy: When did it start?__________________ How many stings you had at the first time?_______
Where was the sting? __________what were the symptoms? ________________________________________
What was the treatment?____________________________________________________________________
Do you have an Epipen?_______ Have you been stung after the first one ?_____If yes, How many times?_____
Describe the reactions and their treatments: _____________________________________________________
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Drug Allergy: Please list medications names, when you had the reaction and what was the reaction.
Please use one line for each medication, thanks. __________________________________________________
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What are other diseases you might have/had? ___________________________________________________
What are other things you are allergic to not mention above like food, chemicals or other drugs? Please,
write each on a separate line, when it happened and the reaction to it.
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The date of the last tetanus and pneumonia vaccines, if known:____________________________________
What are the health conditions that run in your family? Check beside the one applicable to you: Allergy_____
Asthma_______ Cancer_______ Diabetes _______High Blood pressure________ Others__________________
Home Environment: How old is your home?______ Is it? Rural _________suburban ________ city_________
Is your House? Single family____ Apartment _____ Mobile _____ Townhouse _____ Others:_______________
Do you have: Public water _____Well water_____ Natural gas for heating or cooking_____________________
Central air/heat________ Window air condition_______ Electric heat_____ Fire Place____________________
Cats _____Dogs______ Please, write other animals inside or outside the house and their number if possible
__________________________________________ Carpet in the bedrooms: ________Living room:_________
Are you renovating/repairing your home?_________ Any smoking inside or outside the house:_____________
Smoking: Do you or did you smoke? ____ If yes, for how many years in your life time did you smoke? _______
What is the average packs per day during these years?_____________________________________________
Please list all other Medications, including vitamins, you take but did not mention above. Please write the
names, dose and for how long you have been taking them. You can also bring the list of medications on a
paper if they are many. You can write any other concerns you might have, Thanks.
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