New Patient Checklist

All new patients must bring their insurance card and valid ID.
Please bring ALL medications to your visit, NOT a list. Bring a list of medical conditions.
Bring copies of labs or medical records related to the visit. (DO NOT FAX) We are not able to access online medical record systems.
Immunology patients: bring copies of all recent labs and vaccination records
Our office sites vary in size and capacity. We recommend patients be accompanied by primary caregivers only.(We are unable to accommodate more than two people per patient).
For the health and safety of our patients and our staff, please refrain from wearing any perfume, cologne or any scented products. FOOD AND DRINK ARE NOT PERMITTED!
It is pertinent that all patients check with their insurance regarding copays, referrals, coverage and deductibles you may be responsible for, DUE AT TIME OF VISIT.
New patients should allow 2-3 hours for their initial visit, .depending on the number and complexity of the medical issues to be evaluated
There is a $35 NO SHOW FEE for any cancellations made within 48 hours of a new patient visit.

Patient First Name

Please complete this field.

PatientMiddleName

Please complete this field.

Patient Last Name

Please complete this field.

Age

Please complete this field.

Date of Birth

Please complete this field.

Address

Please complete this field.

Home Phone

Please complete this field.

Cell Phone

Please complete this field.

Email Address

Please complete this field.

Marita Status

Please complete this field.

Patients Occupation

Please complete this field.

Work Phone No.

Please complete this field.

Employers Name

Please complete this field.

Emergency Contact (Name, Number, Relation)

Please complete this field.

Primary Care Physician (Name and Number)

Please complete this field.

Referring Physician (Name and Number)

Please complete this field.

Pharmacy (Name and Number)

Please complete this field.

FINANCIAL RESPONSIBILITY

Name

Please complete this field.

Date of Birth

Please complete this field.

Relationship

Please complete this field.

Address(If different from above)

Please complete this field.

Phone Number(If different from above)

Please complete this field.

INSURANCE INFORMATION

Name of Insurance Company

Please complete this field.

Policy Holders Name / Relationship

Please complete this field.

Date of Birth

Please complete this field.

Member ID Number

Please complete this field.

Group Number

Please complete this field.

Secondary Insurance

Please complete this field.

I consent to treatment necessary for the care of the above patient. I authorize the release of all medical records to the referring and family physicians and to my insurance company, if applicable. I allow fax transmittal of my medical records, if necessary. I understand that payment of copays incurred is due at the time of services. I further agree to pay all reasonable attorney fees and collection costs in the event of a default on my account. I further authorize and requests that insurance payments be made directly to Advanced Allergy & Asthma, Dr Kumar Patel. I have read and fully understand the above.

Signature of Patient / Parent / Guardian

Please complete this field.

Date

Please complete this field.

NEW PATIENT QUESTIONNAIRE

Name

Please complete this field.

Age

Please complete this field.

Date of Birth

Please complete this field.

Date

Please complete this field.

Reason you're being seen?

Please complete this field.

When did your symptoms first begin?

Please complete this field.

When, if so, did they get worse?

Please complete this field.

Are your symptoms:

Please select an option.

Check the worst months :

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

What makes your symptoms worse?

Irritants

Smoke

Air Pollution fumes or car exhaust

Strong odors or perfumes

Weather

Cold Air

Rapid Temperature Change (e.g. going from cold outdoors to indoor heat)

Medicine

Aspirin

Non-steroidal anti-inflammatory agents(e.g Motrin,Advil,Aleve)

Allergens

Grass/tree/weeds

Dust or Vacuuming

Damp/Musty Area

Animal(dog,cat,others)

Social History

Occupation / Job / School:

Please complete this field.

Smoking Status:

Please select an option.

Secondhand smoke exposure

Please select an option.

Pets in the home:

Please select an option.

Housing

Please select an option.

Heating:

Please select an option.

Humidifier

Please select an option.

Bedding:Pillow:

Please select an option.

Comforter:

Please select an option.

Flooring: Bedroom:

Please select an option.

House

Please select an option.

Hobbies/Sports

Please complete this field.

Check any of the Illnesses/medical conditions that you have had.

Asthma

COPD

High Blood Pressure

Hay Fever

Pneumonia

Anxiety

Heart Attack / angina

Atopic Dermatitis / eczema

Headaches

Arthritis

Osteoporosis

Diabetes

Irritable Bowel

Thyroid Bowel

Heartburn / acid reflux

Psoriasis

List all surgeries / Operations / Hospitalizations

Please complete this field.

List all presscription and over the counter medications you are currently using (Name & Dosage):

Please complete this field.

What medications have you tried for your allergy problems in the past? Has it been effective?

Please complete this field.

Are you allergic to any medications? If so, list drug, type of reaction and when:

Please complete this field.

Allergy Review of Symptoms - Check all that apply or are abnormal:

Headaches:

Frontal

Maxilla

Temporal

Sinusitis:

Location

Please complete this field.

Snoring

Sleep Apnea

Eyes:

Redness

Itch

Tearing

Puffiness

Ears:

Freq-Infect

Pain

Tubes

Tubes Age

Please complete this field.

Pressure / Congestion

Nose:

Coids

Itch

Runny Nose

Bleeding

Stuffness

Sneezing

Post Nasal Drip

Decreased Sense of Smell / Taste

Throat:

Freq-Infect

Clearing Freq

Bad Breath

Voice Change

Sore Throat

Hoarseness

Swollem Glands

Tonsils or Adenoids removes (Age)

Please complete this field.

Asthma:

Chronic Cough

Bronchitis/Pneumonia

Shortness of Breath

Chest Tightness

Wheezing

Skin::

Eczema

Urticaria(hives)

Insect Bites

Contact Dermatits

Atopic Dermatitis(eczema)

Angioedema(swelling)

GI:

Nausea/Vomiting

Bowel Change

Appetite Change

Lactose Intolerance

Jaundice

GU:

Infection

Blood in Urine

Incontinence

Burning Urination

General:

Weight Loss

Emotional Problems

Sleep Pattern

Missed School / Work

Muscle Aches

Night Sweats

Number of Courses of Antibiotics in Past 12 Months:

Please complete this field.

Do you know of any blood relatives who have or had the following? Please check and give relationship.

Asthma

Allergic Rhinitis / Hay Fever

Food Allergies

Atopic Dermatities / Eczema

Thyroid Disease

Angioedema (Hereditary Angioedema)

Hives (Urticaria)

Physician

Please complete this field.

Date

Please complete this field.

Subscribe to updates from Advanced Allergy & Asthma