New Patient | Chester County Allergy

Please enter ONLY THE FIRST 2 LETTERS of the patient first name*

Please enter ONLY THE FIRST 2 LETTERS of the patient LAST name*

Date of Birth*

MM

DD

YYYY

Have you ever been a patient of Dr. Effat before?*

Date of your appointment*

Time of the appointment*

: HH

MM

Please describe the main reason that prompted you to seek this consultation:*

PLEASE CHECK THE BOXES AND COMPLETE THE BLANKS, WHICH APPLY TO YOUR SYMPTOMS, EITHER CURRENTLY OR IN THE RECENT PAST

Eyes

Itching

Tearing

Comments

Nose and Sinus Symptoms

Sneezing

Itching

Blockage

Nasal secretions

Type of secretions

Snoring
Impaired Smell/Taste.
Sinus Infections
Nasal Polyps

Comments

Throat

Sore Throat

Hoarseness
Post Nasal Drainage

What is the drainage like?

Comments

Ears

Earache

Comments

Headache

Severity?

Mild
Moderate
Severe

Comments

Chest

Coughing

Wheezing

Chest tightness

Shortness of breath

Difficulty breathing
Chest pain
Chest phlegm

Select type of phlegm

Chest symptoms are

Mild
Moderate
Severe

When do you experience these symptoms?

With Colds
With Exercise
At Sleep
When Wakes Up

How often do your chest symptoms occur?*

Do you use rescue inhalers?

( Albuterol, Proventil, Ventolin, Xopenex)

How often?

Do you use a nebulizer?

How often?

If you were ever diagnosed or told that you have asthma, please fill the following questionnaire:

Asthma Control Questionnaire

During the past 4 weeks

How much of the time did your asthma keep you from getting as much done as normal at work at school or at home?

How often did you have shortness of breath?

How often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or chest pain) wake you up at night, or earlier than usual in the morning?

How often did you use a rescue inhaler or nebulizer medications (such as albuterol or Xopenex)?

How would you rate your asthma control?

SMOKING

Did you ever smoke?*

What did you smoke?

Cigarettes
Cigars
Pipe
Other

How many a day?

When did you start smoking?

Did you quit smoking?

When did you quit smoking?

Did you grow up with smoking parents? *

Skin

Dry

Itching

Rash

Which part of the body?

GENERAL SYMPTOMS PATTERN

When did your current symptoms start this time?*

Please enter a number

*

Did you ever have similar symptoms in the past?*

When was the very first time?

Please enter a number, e.g. 01, 07, 10, 39, 46, etc.

Symptoms have been

DO YOUR SYMPTOMS AFFECT THE QUALITY OF YOUR LIFE?

Symptoms adversely affect

WHAT TIME OF THE YEAR ARE YOUR SYMPTOMS NOTICEABLE?

FACTORS THAT TRIGGER OR AGGRAVATE YOUR SYMPTOMS

Which food?

What else triggers your symptoms?

PAST EXPERIENCE WITH VARIOUS TREATMENT MODALITIES

Please check the type of treatment modalities that has been previously used.

Eyes & Nose

Please enter the names of the medication that you've used

Bronchodilators

Nebulizer
Inhalers
Epinephrine injections

Please enter the names of the medication that you've used

Steroids

Nasal sprays
Lung inhalers
Oral
Injections

Please enter the names of the medication that you've used

Others

Singulair
Prescription creams

Please enter the names of the medication that you've used

Disease Modification

Allergy testing
Allergy education
Allergy injections

Other

REVIEW OF SYSTEM

Please check if you CURRENTLY or INTERMITTENTLY have any of the conditions listed below

Please check if you CURRENTLY or INTERMITTENTLY have any of the conditions listed

Contraception method

Other Conditions

IMMUNIZATIONS: (check which immunizations you have had in the past 5 years)

PAST MEDICAL HISTORY

(Please check if you IN THE PAST BUT NO LONGER have any of he conditions listed below)

Other conditions

Other conditions

Surgeries

Surgeries

Please list type and dates of syrgeries

Hospitalized

Hospitalized

Please list dates and reasons of hospitalization

History of emergency room visits?

Please write reasons and dates of ER visits.

During the past year have you missed days of school/work due to your condition?

Yes

How many days missed during the past year

During the past year how many doctor visits have you had due to your condition?

visits

Please write reasons and dates.

NEWBORN & INFANCY HISTORY

Please check this box if patient is under 12

Patient IS under 12 years of age

Fill this section if the patient is less than 12 years of age

Please list complications during delivery or during the newborn days

Comlications during delivary and newborn period

Was breast fed?

Breast Fed

For how long?

Was infant formula used?

Infant formula was used

When was formula introduced?

For how long?

Which formula was tolerated?

Was any of the formulas not tolerated?

Yes

which formula was not tolerated?

Formulas NOT tolerated

At what age regular milk was introduced?

At what age Solid Food was introduced?

Problems during the first couple of years of life

HOW WOULD YOU GRADE YOUR SYMPTOMS IN GENERAL?

Least : 1 Worst : 10

HOW MUCH DO YOUR SYMPTOMS AFFECT THE QUALITY OF YOUR LIFE?

Least : 1 Worst : 10

Family History

Allergy

Hay Fever

Asthma

Eczema/ Dry Skin

Hives

Headache

Emphysema

Cystic fibrosis

Allergy to medications

Immunodeficiency

High blood pressure

Heart disease

Arthritis

Diabetes

Seizures

Mother

Other history

Father

Other history

Siblings

Other history

Others on Mother's side

Other history

Others on Father's side

Other history

Environmental Survey

Type of dwelling

House
Apartment
Summerhouse

Location(s)

City
Suburb
Country
Seashore

How long've you lived there?

ex: 1 year

How old is it?

ex: 1 year

Heating system

Other heating systems

Fireplace
Wood stove
Kerosen heater

How often they are used?

Air Conditioning

Central
Wall/window mound
No airconditions

Windows

Ancillaries

Fiberglass filter
High efficiency filter
Electrostatic
Air cleaners

Basement

Dry
Wet
Moldy

Washer and Dryer

Washer and Dryer

Where?

Clothesline

Clothesline

House Flooring

Area rugs

Bedroom

area rugs
Dust proof zippered encasements for bedding
Dust collecting items

Animals*

Cat
Dog
Bird
Rabbit

Other

Farm Animals

Household Smokers*

Who smokes

Where do they smoke?

Describe your workplace /school

School
Work

Please describe

Please fill in the personal characteristics that apply to you

Additional house hold members

Exercise type(s)

Exercise Details

What type of exercise

How many times a week?

Hobbies

Hobby Details

Do you drink alcohol?

Beer
Wine
Other

How much?

Alcohol or chemical dependency?

Self
Family history
Sleeping problems

Marital/Family adjustment

Difficult
Average
Easy

Work/School adjustment

Difficult
Average
Easy

Financial problems

Difficult
Average
Easy

Tendency to worry/anxiety/panic

Difficult
Average
Easy

CURRENT MEDICATIONS

(Include over the counter, vitamins, herbals and dietary supplements.)

Name

Dosage

ADVERSE REACTION TO MEDICATIONS

(Include over the counter, vitamins, herbals and dietary supplements.)

Date

Name

Describe Reaction

New Patient Registration

New Patient Medical History Form:

PLEASE CHECK THE BOXES AND COMPLETE THE BLANKS, WHICH APPLY TO YOUR SYMPTOMS, EITHER CURRENTLY OR IN THE RECENT PAST

Eyes

Nose and Sinus Symptoms

Throat

Ears

Headache

Chest

If you were ever diagnosed or told that you have asthma, please fill the following questionnaire:

Asthma Control Questionnaire

SMOKING

Skin

GENERAL SYMPTOMS PATTERN

PAST EXPERIENCE WITH VARIOUS TREATMENT MODALITIES

REVIEW OF SYSTEM

PAST MEDICAL HISTORY

NEWBORN & INFANCY HISTORY

Family History

Environmental Survey

CURRENT MEDICATIONS

ADVERSE REACTION TO MEDICATIONS