New Patient Registration and Medical History. Address City State Zip code
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1 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA New Patient Registratin and Medical Histry Name Tday s date Address City State Zip cde Hme phne Cell phne Birth date Sex M/F Marital status Scial security # Occupatin & emplyer/schl Race/Ethnicity Referring physician Preferred pharmacy name & phne # Primary care physician Mail rder pharmacy What is the reasn fr yur visit tday? If yu have been given a diagnsis by anther physician, please specify it here, as well as the diagnsis cde if knwn. PAYMENT AND INSURANCE INFORMATION Please nte that we will need t cpy yur pht ID and insurance card. Primary Insurance Member ID# Grup name Grup/Plan # Plicy hlder/subscriber name Relatinship t patient Plicy hlder/subscriber birth date Phne number Plicy hlder/subscriber address Secndary Insurance (if applicable) Member ID# Grup name Grup/Plan # Plicy hlder/subscriber name Relatinship t patient Birth date Financially respnsible party If the patient is a minr, t whm shuld bills be sent? Name Relatinship t patient Date f birth Phne number Address City State Zip cde Page 1 f 6
2 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA ALLERGY AND ASTHMA HISTORY Patient name Yes N If yes, please answer the questins belw: Have yu ever been diagnsed with asthma? At what age? Any hspitalizatins fr asthma? When? Any ER visits fr asthma? When? Any ral sterids (prednisne) fr asthma? When? Have yu ever had allergy testing befre? When? By whm? Were yu n allergy shts? Have yu ever been diagnsed with eczema? D yu see a dermatlgist? Have yu had adverse reactins t fds? Have yu had adverse reactins t medicatins? Have yu had adverse reactins t bee stings? Have yu had adverse reactins t latex? Page 2 f 6
3 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA PAST MEDICAL HISTORY Please indicate if yu have, r are being treated fr, any f the fllwing: Yes N Yes N Cataracts Glaucma Anemia Diabetes Thyrid disease Lupus Rheumatid arthritis Osteprsis Celiac disease Psriasis Pneumnia Ear infectins High bld pressure High chlesterl Heart disease COPD (emphysema) Sleep apnea Nasal plyps GERD (heartburn) Anxiety Depressin Cancer (specify type) Sinus infectins Headache/Migraine D yu have any ther medical prblems? Please specify. SURGICAL/HOSPITALIZATION HISTORY Please indicate if and when yu have had any f the fllwing prcedures: Tnsillectmy Adenidectmy Ear tubes Sinus surgery Nasal surgery Nasal plypectmy Yes N When Have yu had any ther surgery? If yes, please specify the prcedure and year it was perfrmed. Have yu had any ther hspitalizatins unrelated t surgery? If yes, please explain. Page 3 f 6
4 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA FAMILY HISTORY Has anyne in yur family (bld relatives) been diagnsed with any f these cnditins? If yes, please specify wh: Yes N Wh? Yes N Wh? Asthma Allergic rhinitis/hay fever Eczema Fd allergies Cataracts Glaucma Thyrid disease Lupus Celiac disease Rheumatid arthritis Urticaria (hives) Angiedema (swelling) COPD/Emphysema Osteprsis Cancer (type?) Diabetes Hypertensin High chlesterl MEDICATIONS Please list yur current medicatins and dses Medicatin Dse Frequency Page 4 f 6
5 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA ENVIRONMENTAL HISTORY Yes N If yes, please answer: D yu have pets at hme, r are yu arund animals when away frm hme? What kind, and hw many? Have yu ever smked? Hw much, and fr hw lng? D yu want t quit? Des anyne smke arund yu? D yu g t schl r daycare (children)? What is yur ccupatin (adults)? Is there anything yu are expsed t that yu believe triggers yur symptms? Any seasn when they get wrse? IMMUNIZATIONS Yes N Children: Are yu up t date n all f yur childhd vaccines? Adults: 1. D yu get an annual flu sht? 2. Have yu ever received Pneumvax (pneumnia vaccine)? Page 5 f 6
6 Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724) / Fax (724) Bradfrd Rad, Suite 410, Wexfrd, PA REVIEW OF SYSTEMS Are yu currently experiencing any f the fllwing symptms? GENERAL MOUTH/THROAT MUSCULOSKELETAL Fever Chills Fatigue Itchy thrat Sre thrat Frequent thrat clearing Harseness Muscle pain Jint pain Jint stiffness Jint swelling Jint redness/warmth EYES NECK SKIN Red Watery Itchy Swelling Lumps Rash Hives Itching Flaking/peeling Swelling Redness/flushing EARS RESPIRATORY NEUROLOGIC Pain Fullness/ppping Itching Cugh Wheeze Difficulty breathing Chest tightness Truble with exercise Headache Dizziness/vertig NOSE GASTROINTESTINAL PSYCHIATRIC Stuffy/cngested Itchy Runny Sneezing Lss f sense f smell Pst nasal drip Sinus pressure Nsebleeds Stmach pain Heartburn Nausea Vmiting Diarrhea Cnstipatin Stressrs Sleep disturbance Page 6 f 6
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A photocopy of this document shall be considered as effective and valid as the original.
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