NEW PATIENT INTAKE SHEET
Allergy and Asthma Center
Anita N. Wasan, MD, FAAP, FACAAI
Lauren H. Vogan, PA-C
Natalee J. Palacio, PA-C
(Please Print)
DATE: _________________________________
PATIENT NAME: ___________________________________________________________________
PHONE NUMBER: ___________________________________________________________________
ARE YOU TAKING A BETA BLOCKER:
YES: _________
NO: __________
IF SKIN TESTING, HAVE YOU HAD AN ANTIHISTIMINE WITHIN THE PAST 5 DAYS?
YES: ______
NO: ______
VITALS (For office use only):
BP: ___________HR: ___________TEMP: ___________HEIGHT: _______ft. ________in. WEIGHT: _______________lbs.
PATIENT INFORMATION:
PATIENT DOB: ______________________________
PRIMARY CARE PHYSICIAN:
__________________________________________________________________________________
REASON FOR VISIT: __________________________________________________________________________________
PLEASE LIST YOUR OCCUPATION:
__________________________________________________________________________________
ARE YOU ALLERGIC TO ANY MEDICATIONS/LATEX? (Please list):
1) _________________________________
2) _________________________________
3) ___________________________________
4) ___________________________________
LIST ANY MEDICATIONS TAKING TO INCLUDE “OVER-THE-COUNTER” MEDICATIONS (To include
dosage/frequency):
1) ________________________________
3) ________________________________
2) ________________________________
4) ________________________________
DO YOU HAVE ANY MEDICAL CONDITIONS (Please list):
__________________________________________________________________________________________________
HAVE YOU EVER BEEN HOSPITALIZED/HAD ER VISITS/ANY SURGERIES? (Please list):
__________________________________________________________________________________________________
DO YOU HAVE ASTHMA/BEEN HOPSPITALIZED/HAD ER VISITS FOR ASHTMA? IF YES, PLEASE LIST WHEN YOUR LAST
SYMPTOMS WERE AND DATES OF HOSPITALIZATION:
__________________________________________________________________________________________________
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?
•
Eczema: _______________ _
•
•
Ear Infections (How many):
________________________
Sinus Infections (Average number/Year or
total): ________________________________
•
Strep Throat or Pharyngitis (Average
number/Year or total):____________________
•
Bronchitis (Average number/Year or
total):___________________________
HOW OLD IS YOUR HOME: _______________
HOW OLD IS YOUR CARPET: _______________
DO YOU LIVE WITH ANY PETS? (If yes, please list how many and what type):
__________________________________________________________________________________________________
HAVE YOU EVER AND/OR USED TOBACCO PRODUCTS? YES__________
NO__________
(IF YES) WHEN? : ____________________________________________________________________________________
IS THERE ANY TOBACCO EXPOSURE IN YOUR HOME AND/OR WORK?
DO YOU DRINK ALCOHOL?
YES__________
YES__________
NO__________
(If yes how often) ____________________
NO__________
LIST ALL MEDICAL CONDITIONS THAT EXIST IN YOUR FAMILY INCLUDING WHO HAS THEM:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Pharmacy Name: _________________________________________ City/State: _________________________________
Pharmacy Number: __________________________________________________________________________________
ARE YOUR IMMUNIZATIONS UP TO DATE? YES: ______________
NO: ___________________
SYSTEM REVIEW: (Please circle any of the following symptoms/condition that you have):
•
Blurry Vision/Visual
Problems
•
Heartburn
•
Diarrhea/Constipation
•
Pain/Swelling of Joints
•
Sneezing/Nasal Congestion/
Runny Nose
•
Rash/Skin Problems
•
Hair Loss
•
Numbness of Extremities
•
Difficulty in Urination
•
Back Pain
•
Abdominal Pain
•
Wheezing
•
Thyroid Problems
•
Itchy Eyes
•
Gas/Bloating/Flatulence
•
Cough
•
Cold/Heat Intolerance
•
Musculoskeletal Pain