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Dr. Singh New Patient Questionnaire
Step
1
of
4
25%
Name
First
Last
For children' hov, is the accontpanying adult(s) related to chitd?
Date of Birth
*
MM slash DD slash YYYY
Age
Gender
Male
Female
Referring Doctor's name:
Check if self-referred
Reason for visit: (please list main symptom and how long patient had this symptom)
Constitutional
Fever
Yes
No
Weight loss
Yes
No
Wheezing
Yes
No
Shortness of breath
Yes
No
Chest tightness
Yes
No
Eyes
Itchy eyes
Yes
No
Redness of eyes
Yes
No
Watering of eyes
Yes
No
Allergic shiners
Yes
No
GI
Heartburn
Yes
No
Regurgitation
Yes
No
Acid taste in mouth
Yes
No
Vomiting
Yes
No
ENT
Sneezing
Yes
No
Itchy nose
Yes
No
Stuffy nose
Yes
No
Smell/taste
Normal
Reduced
Plugged ears
Yes
No
Itchy ears
Yes
No
Throat clearing
Yes
No
Post-nasal drip
Yes
No
Sore throat
Yes
No
Snoring
Yes
No
Sirrus pain/pressure
Yes
No
Hoarseness
Yes
No
Skin
Eczema
Yes
No
Hives
Yes
No
Angioedema
Yes
No
Neuro
Headache
Yes
No
Seizures
Yes
No
Hem/Onc
Pallor
Yes
No
Enlarged glands
Yes
No
Cardio
Palpitation
Yes
No
Chest pain
Yes
No
All/lmm
Food allergies
Yes
No
Bee sting allergy
Yes
No
Resp
Cough
Yes
No
Musculoskeletal
Arthritis
Yes
No
Raynaud's
Yes
No
PFSH
Current medications
Please list names of medication, dose and how long taken.
Previous treatment
Please list previous treatments
Medication allergies
is the patient allergic to any medication? If so, please list the name of the medication and nature of the reaction (i.e. rash, diarrhea, etc.)
Past medical history
Please list any previous illnesses/injuries/surgeries
Previous allergy testing/allergy shots?
For children under 5 years of age
Birth weight
Full term/pretern
weeks
Breathing problems after delivery?
Breast fed/formula fed? Name of formula
Any problems with growth (weight or height)?
Immunizations-up to date?
Yes
No
Family history or allergies
Asthrna
Hay fever
Sinus allergies
Eczema
Food allergies
insect sting allergies
medication allergies
hives/angioedema
immunodeficiency
anaphylaxis
exercise asthma
nasal polyps
GI reflux
collagen disease
cystic fibrosis
Social history
Occupation (for children-name of school and grade):
Missed school/work?
How much?
Does patient smoke now or in the past?
Yes
No
How many years?
How many packs/day?
Is patient exposed to smoke? If yes, where?
Hobbies
Environment
Patient exposed to pets? If yes, explain.
How old is your house?
Urban/suburban/rural
Stuffed toys
few
lots
Rooms
Carpeted
Hardwood
Indoor plants
few
several
Basement
damp
dry
Please note: additional questions will depend on the reason for your visit. Appropriate forms will be provided if necessary.
Respiratory Allergy Questionnaire
Nasal/sinus/ear/throat symptoms:
Severity of nasal/sinus symptoms
mild
moderate
severe
Please grade symptoms on a scale of 1-4
Spring
Summer
Fall
Winter
Are symptoms worse in the morning upon awakening?
Triggers for nasal/sinus/ear/throat:
Grass
weeds
trees
cat
dog
dust
Mold/mildew
raking leaves
air conditioning
basement
Weather
cold
heat
wind
smog
Chemicals
paint
perfurme
soaps/detergents
cosmetics
aerosols
smoke
wool
exercise
pregnancy/menstruation
Foods: (please list)
How many sinus infections in the past year?
Ear infection?
Throat infections?
Chest symptoms
cough
wheezing
congestion
breathing difficulty
How long has the patient had chest symptoms?
MM slash DD slash YYYY
Duration of typical episode in day
Frequency of episodes in months
Frequency of episodes in year
breathing treatment time of medication
Oral steroids (Orapred/pediapred/prednisone)?
Antibiotics-name?
How many times does the patient have cough/wheezing/shortness of breath?
Daytime
Daily
12-6 times a week
less than once a week
Nighttime
less than 2 x month
2 x month
more than 2 x month
How often do you use rescue inhaler (puffer)
daily
2-6 times a week
less than 1 time a week
How many ER/Urgent doctor visits for asthma in the past 6 months?
Ever hospitalized or admitted to intensive care unit for asthma? If yes, please explain...
Upper respiratory infections (head colds/sinus infections)
Grass
weeds
trees
cat
dog
dust
Mold/mildew
raking leaves
air conditioning
basement
Weather
cold
heat
wind
smog
Chemicals
paint
perfume
soaps/detergents
cosmetics
aerosols
smoke
wool
pregnancy/menstruation
Foods: (please list):
Does patient have recurrent bronchitis/croup/asthma./reactive airway disease/pneumonia?
Does patient have prolonged chest congestion following a virus/cold?
Yes
No
Does patient have exercise-induced cough, wheezing oishortness of breath?
Yes
No
At what age did eczema start?
Location
scalp
face
chest
abdomen
back
arms
legs
Ttiggers
Seasonal
spring
summer
fall
winter
Soap
shampoo
woolen clothing
jeans
Foods: (please specify)
Hives
How long has the patient had hives?
Location
scalp
face
neck
chest
abdomen
back
arms
legs
Itching
mild
moderate
severe
Is itching worse at night?
Does the rash (hives) come and go, keep moving or persist in one sot for more than 24 hours?
Any bunring/pain or bruising at the site of the rash (hives)?
Lip swelling, tongue swelling, throat swelling, breathing problems associated with hives?
Triggers
soap
shampoo
woolen clothing
cosmetics
detergents
conditioners
Pressure areas
belt line
bra line
tight socks
Triggers
Heat
exercise
sweating
cold exposure
sun
pressure
vibration
Medication
aspirin
Motrin
Aleve
and other pain relievers of the NSAID family
Foods:
please list any foods, dyes, wine, MSG, that may be thought to cause hives.
Bee Sting Allergy
When did the reaction(s) occur?
Describe the setting:
Local swelling or
Generalized hives, eyelid swelling, lip and tongue swelling, throat swelling, Breathing problems, dizziness or loss of consciousness
Food or medication allergy:
For each of the foods or medication suspected of causing a reaction, list the date when the reaction occurred, symptoms during the reaction and how long it took to resolve,
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