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NEW PATIENT CONSULT FORM
Bay Shore Allergy & Asthma Specialty Practice, P.C.
Asthma, Allergy, Clinical Immunology & Pediatric Pulmonary Specialists
649 Montauk Highway
West Bay Shore, NY 11706
www.bayshoreallergy.com
Louis E Guida Jr, MD FCCP
Janet Kelske, MS CPNP, ANP-C
Tel: (631) 665-2700
Fax: (631) 665-0290
PATIENT HISTORY
DATE: _____/_____/_____
NAME: ___________________________________ DOB: _____/_____/_____ SEX: ________
ADDRESS: __________________________________________________________________
HOME PHONE: _________________________ CELL PHONE: ________________________
PRIMARY CARE PROVIDER: ___________________________________________________
ADDRESS: __________________________________________________________________
TELEPHONE: __________________________ FAX: _________________________________
1. PLEASE DESCRIBE IN YOUR OWN WORDS THE REASON FOR YOUR VISIT:
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2. HOW LONG HAS THIS BEEN A PROBLEM?
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3. IS IT PRESENT ALL YEAR ROUND OR ONLY AT CERTAIN TIMES OF THE YEAR?
4. CIRCLE ANY OF THE FOLLOWING THAT CAUSE THE PATIENT TO HAVE PROBLEMS:
DUST
DAMPNESS
FEATHER PILLOWS
ANIMALS
TREES-GRASS-WEEDS
CIGARETTE SMOKE
EXERTION (RUNNING)
HAIR SPRAY
INSECT SPRAY
EXCITEMENT/EMOTIONS
SUMMER HEAT
INDOOR HEAT
MOLD/MILDEW
PERFUME
NEWSPAPERS
COLD AIR
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NEW PATIENT CONSULT FORM
5. HAS THE PATIENT EXPERIENCED ANY OF THE FOLLOWING? (NOW OR IN THE
PAST). CIRCLE THOSE THAT APPLY:
ASTHMA
BRONCHITIS
WHEEZING
COUGHING
HEARTBURN
SHORTNESS OF BREATH
SPITTING UP
ITCHING/RASHES
PNEUMONIA
HIVES/SWELLING
6. DOES THE PATIENT HAVE OR SUSPECT ANY FOOD ALLERGIES? IF SO, WHICH
FOODS?
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7. IS THE PATIENT ALLERGIC TO ANY MEDICATIONS, SOAPS OR DETERGENTS? IF SO,
PLEASE LIST THEM:
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8. LIST ANY MEDICATIONS THAT THE PATIENT IS NOW TAKING:
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9. LIST ANY MEDICATIONS THAT WERE TRIED IN THE PAST THAT WERE NOT
EFFECTIVE IN TREATING THE PROBLEM: (INCLUDE OVER THE COUNTER
MEDICATIONS).
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10. IS THE PATIENT ABLE TO SWALLOW PILLS? YES_____ NO_____
PHARMACY NAME: _______________________________ TELEPHONE #: _____________
ADDRESS: __________________________________________________________________
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NEW PATIENT CONSULT FORM
1. DOES YOUR INSURANCE COMPANY ALLOW FOR PRESCRIPTIONS TO BE WRITTEN
FOR 90 DAYS AT A TIME (MAIL AWAY) OR JUST 30 DAYS? _________________________
2. IS THERE ANY PAST MEDICAL HISTORY THAT WE NEED TO KNOW ABOUT?
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3. HAS THE PATIENT HAD A CHEST X-RAY WITHIN THE PAST 12 MONTHS?
IF YES, WHAT WERE THE RESULTS? GOOD ________ BAD ________
4. ARE THERE ANY PETS IN THE HOME? YES ______ NO ______
IF YES, WHAT KIND OF PETS? _________________________________________________
5. DOES THE PATIENT SMOKE? YES ______ NO ______
IF YES, HOW MUCH PER DAY? _________________________________________________
6. DOES ANYONE ELSE SMOKE IN THE HOME? YES ______ NO ______
7. IS THERE A FAMILY HISTORY OF ALLERGY, ASTHMA, HAY FEVER, SINUS DISEASE,
BRONCHITIS OR HIVES?
FAMILY MEMBER
MOTHER
FATHER
SISTERS
BROTHERS
AUNTS
UNCLES
COUSINS
YES
NO
TYPE OF ALLERGY
PSYCHOGENIC FACTORS:
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