New Patient Form

New Patients
Appointment Location*

In PersonTelemedicine
Patient's Full Name*

First NameLast Name
What is your Gender?

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Referring Doctor
What is your occupation?
Your Doctor*

BalekianOrenPalumboMaciagSchaeferYakaboski
Appointment Date*

MonthDayYear
Date
Appointment Time*

:HourMinutesAM/PM Option
What is the reason for your visit? (Symptoms, when they occur, what seems to trigger them)*
Past Medical History*

NONEAsthmaCancerCardiac diseaseDiabetesHeartburn/refluxHypertensionPsychiatric disorderThyroid diseaseAutoimmune diseasePremature birthOther
Are you Allergic to any medications? (if yes, please list)

NoOther
Current Medications*
Does anyone in your family have a history of:

AsthmaNasal allergiesEczemaFood AllergiesMedication AllergiesBee Sting Allergy
Do you live in a:

HouseApartmentDuplexCondo/TownhouseOther
What type of flooring in your bedroom?

wall-to-wall carpetinghardwood flooringarea rugsOther
Any pets in the house?
Do you use or have history of using tobacco? Live with smoker? Select all that apply
Do you use or have history of using tobacco? Live with smoker? Select all that apply

No/NeverYes - currentlyQuit/FormerSmoker in house
Do you experience any of the following? Check all that apply:*

Recurrent FeversFatigueWeight GainWeight LossBlurred VisionLight FlashesHearing DifficultyNose BleedsHoarsenessNeck SwellingFluttering HeartChest PainSwollen AnklesCoughWheezeShortness of BreathPoor Exercise ToleranceHeartburnStomach PainsVomitingDiarrheaPain on UrinationExcessive SweatingConstant ThirstFeeling too WarmFeeling too ColdPainful/Swollen JointsRashesItchingDepressionAnxietyNONE OF THE ABOVE
Please sign to authorize us to access your medical records through CareEverywhere

Clear
Should be Empty:

New Patients