New Patient Intake Form

Allergy and Asthma Center, Anita N Wasan MD PLC
Date of Visit

Month Day Year
Date
Patient Name
Address
Cell phone number
Email address
example@example.com
Insurance name & ID
Subscriber name, DOB, social security number
Reason(s) for Visit:
Are you able to get skin tested today? (You have not had any antihistamines for 3-5 days)
Do you take beta blockers for heart palpitations/ high blood pressure/anxiety?
Do you have trouble breathing/ cough/shortness of breath? If yes, you may need breathing tests done.
Please list primary care provider and any specialist physicians you see including city, state
Please list any hospitalizations, surgeries, and medical conditions you have
Any drug allergies? If yes, please list approximate age of reaction and symptoms
List all medications (prescription and over the counter) including dosage
Type of housing (i.e. single family home, townhome, condo, apt)
When was the home built?
Any pets? If yes, please list how many and what type.
Do you smoke? Have you ever smoked? Are you exposed to smoke? Include e cigarettes and marijuana and hookah
How many alcoholic beverages do you drink per week, on average?
Does your home have carpeting? Where and how old?
Any mold or water damage in the home?
Do you change your air filters? If yes, how often ?
Any indoor plants? Where and how many?
Do you snore? Any nightly awakenings? Mouth breathing at night? Do you wake up in the morning feeling well rested?
How often do you change your sheets and pillowcases? How old is your mattress?
How many servings (8 oz) of caffeine do you drink per day? Include coffee, sodas, iced tea, etc.
Do you eat spicy foods 2 3 times a week or more? Do you have difficulty swallowing?
Allergy and Asthma Center, Anita N Wasan MD PLC
Please list any medical conditions that exist in your family
For those patients with hives, rashes, sensitive skin, and/or eczema:
Name of body wash/soap:
Name of washing detergent:
Do you use dryer sheet and/or fabric softeners?
Do you use perfumes/colognes/body sprays?
Preferred pharmacy name and location:
Circle any symptoms that pertain to you:

Headaches Nasal congestion Suicidal thoughts Lymph node swelling

Vision loss/changes Trouble falling asleep Nerve pain/tingling

Breat lumps/masses Hearing loss/changes Trouble staying asleep

Arthritis/joint pain Constipation Sinus pressure Snoring Rash/eczema

Diarrhea Post nasal drip/throat closing Mouth breathing Hives

Bloating/gas Cough Heart palpiations Difficulty in moving extremities

Abdominal pain Chest pain Depression Swelling Nausea/vomiting

Shortness of breath Anxiety Neck pain Difficulty in urination

Menstrual irregularities Hair loss Cold/heat intolerance Thyroid problems

Difficulty breathing Frequent illnesses Food allergies Food sensitivities
Should be Empty:

Reason(s) for Visit:

For those patients with hives, rashes, sensitive skin, and/or eczema: