Please Print When Filling Out This Form

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1 Please Print When Filling Out This Form For Office Use Only Patient #: Location: Date of First Appointment: Patient Information Patient s Name: Home: ( ) Address: _ Street City State Zip E- Mail Address: Cell Phone: ( ) Date of Birth: Sex: M F Relationship Status: SSN: Have you or any other family members received medical care by our practice? Who: When: Physician Information Primary Care Physician (PCP): Phone: ( ) Address: Name of Group Practice: Street City State Zip Specialist: Phone: ( ) Address: Name of Group Practice: Street City State Zip I give permission to send a written report (s) to above Doctors: Yes No How did you first hear about Dr. Tahira Bokhari? (Check One) Primary Care Office Specialist Patient Family Member Friend Insurance Company Pharmacy On-line Employee Other: Employment Information Complete this area for the patient or parent/guardian of a minor Name: Relationship: DOB: SSN: Employer: Phone: Employer Address: City: State: Zip: Employment Information Complete this area for spouse or 2 nd parent/guardian of a minor Name: Relationship: DOB: SSN: Employer: Phone: Employer Address: City: State: Zip: Insurance Ins. Company: Phone #: ( ) Policy Holder: Effective Date: Ins. Address: Street City State Zip Member #: Group #: Emergency Contact Name: Phone: ( ) 2 nd Phone: ( ) FOR OFFICE USE ONLY Billing Procedure I authorize the release of any information necessary to process claims. I request payment of benefits to the office of Dr. Tahira Bokhari. I understand I am financially responsible for charges not covered by this authorization. I understand and agree if care at the office of Dr. Tahira Bokhari M.D. requires Primary Care Physician referral; it is my responsibility to see that the referral is current prior to receiving care at the office. If no referral is present in advance, I agree to pay for charges at the time of service. Signature Relationship to Patient _ Witness Date Consent for care of minors Because my son/ daughter is a minor (less than 18 years of age) and primarily supported by parent or guardian. I understand and agree that he/ she may be evaluated and/ or treated by Dr. Tahira Bokhari M.D. and staff if I am not presented to give consent. This may include, but not necessarily be limited to physical exams, skin tests, laboratory test, allergy injections and the prescription of medications in my absence. This agreement will be effect until revoked by me in writing. Signature Relationship to Patient _ Witness Date

2 New Patient History Patient Name: DOB: First Visit: Were you referred by a physician or other provider? No Yes If yes, who? Major reason(s) for allergy consultations or infectious disease: Complete the following if you have a history of Wheezing, Asthma, Bronchitis or Chronic Cough: Date of symptoms first noted: Approximate Frequency /year: Number of hospitalization for this problem /year: Medication taken for this and their effects: Notice any seasonal changes in these symptoms: Known triggers of asthma attacks: If no, check here Emergency room visit (s) for asthma, how many? Asthma diagnosed by a Physician? Age: Oral steroids (prednisone, Medrol, Prednisolone) taken for asthma If so, number of time taken per year: 1 2 to 3 greater than 3 Date of last use: Lower Respiratory Tract (Chest, Lungs) Problems. History of recurrent bronchitis History of recurrent pneumonia History of recurrent croup Previous chest x-ray or chest CT scan; if so, when? Result: normal abnormal

3 Peak flow meter used; if so, best reading: Pulmonary function (lung) test: yes no Pulmonary (lung specialist) evaluation; when: Specialist s name: Are you physically active on a regular basis (formal exercise, play sports, other types of physical activity): yes no Do you experience a cough, wheezing, difficulty breathing during exercise/ physical activity? Yes No Other symptoms (list): Note: Year round symptoms? Yes No Symptoms interfere with: sleep exercise/activity missed school missed work Symptoms are: improving worsening unchanged Hay Fever, Nose and/ or Eyes Symptoms, Sinus or Headaches Problems, Post Nasal Drip: Yes or No Any seasonal pattern: Yes or No Most severe in: Spring Summer Fall Winter Sneezing: Yes No Itchy Eyes: Yes No Itchy Nose: Yes No Known causes of these symptoms: Pollen Pets Allergen Other: Note: Medications tried for above problems: Current medication Does it work? Past medication Does it work? Prior Surgery:

4 Skin Problems: Eczema: Yes No Location: arms legs trunk head neck Approximate date symptoms first noted: Infancy Childhood Adulthood Hives: Yes No Location: arms legs trunk head neck Approximate date symptoms first noted: Infancy Childhood Adulthood New Rash: Yes No Location: arms legs trunk head neck Approximate date symptoms first noted: Infancy Childhood Adulthood Known causes of these symptoms: Temperature Change Food Cold Air Other Skin Symptoms: itching excessively dry, scaly skin irritated red patches weepy, oozing rash recurrent skin infections welts/hives skin swelling lip swelling face swelling hand/foot swelling throat/ tongue swelling difficulty breathing from swelling. other skin symptoms ( list): Frequency of above symptoms: daily times per week times per month other Do skin symptoms occur year-round? Yes No Season (s) in which above symptoms are worst: spring summer fall winter Has a physician diagnosed your rash? Yes No If yes, what was the diagnosis? hives eczema contact dermatitis other Have you seen a dermatologist for your skin problems? Yes No. If yes, name of doctor: when seen: List everything that causes or aggravates your skin symptoms: Medications tried for above symptoms: Current medication Does it work? Past medication Does it work?

5 Previous Allergy Evaluation (s): Yes No Date: Skin Testing: Yes No Blood testing for allergy: Yes No Were you allergic? Yes No If yes, was it to: animals dust/ mites pollen mold food other Allergist Name: State: Previous allergy injection (s): Yes No Age or date (s) of treatment: How long did you take shots? 6 months 1 year 2 years 3 years longer Were allergy injections effective? No Yes Not sure Adverse reaction to allergy injection (s)? Yes No If yes, list: Insect Sting Reactions: Yes No If yes, insect (s) causing reaction: Symptoms: large swelling at site hives breathing problems dizzy/ lightheaded other (list): Age or date when occurred: Epi-Pen device prescribed? Yes No Known or suspected drug allergies: Yes No Type of medication Reaction (s) noted Age or Date of reaction Is the medication avoided? Known or suspected food allergies: Yes No Type of medication Reaction (s) noted Age or Date of reaction Is the food avoided? Latex or Rubber Allergies/ Intolerances: Yes No If yes, explain:

6 Environmental History: How long has patient lived in New Jersey? What other states/ countries has patient lived in? Primary Home: Type: house townhouse condominium apartment mobile home other: Age of home: less than 10 years 10 to 20 years 20 to 50 years over 50 years Length of time in home: Construction: Basement: none finished unfinished walkout dirt crawl space moisture problem Heating and Cooling: Heat: forced air heat hot water or radiant heat electric heat wood burning stove Cooling system: none central air window air conditioner swamp cooler attic fan Central filter type: none fiberglass HEPA electrostatic Frequency of filter change or cleaning: Air Ducts Cleaned: no yes If yes, when Mold and Moisture: Humidifier: none furnace cold-mist ultrasonic stream Water leak (s): - none past current musty odor visible mold Cleaning: Frequency of dusting: daily 2-3 times per week 1 time per week every 2 weeks less often Frequency of vacuuming: daily 2-3 times per week 1 time per week every 2 weeks less often Patient s Bedroom: Flooring: carpet wood tile linoleum area rug Bed: Mattress: innerspring foam waterbed bunk futon Pillow: feather (down) foam synthetic. Pets: no yes Number How long owned? Outside Inside Bedroom Dog (s) Cat (s) Other (s) Smokers (at your home) No one patient mother father husband wife other Other Environments: Daycare Relative s Home School Work

7 Social History: Has the patient ever smoked? yes no If yes, how many years: Current smoker? yes no If not, when did you quit: How much do/did patient smoke? Number of pack per day less than ½ 1/2 1 2 or more Alcoholic beverages? no yes If yes, shown often: _ Drugs? yes no If yes, how often Family History: Medical Condition Childhood Illness Relative Date Did you/ your child travel aboard in the past year? Yes No Where? Birth History: Normal birthday History Weight at birth lbs. Height at birth in Deliveries: NSVD C- Sections Complications during delivery: None Complications during pregnancy: None How many did the mother give to birth? Boys: Girls: Child care situation: Parent Others ( specify): School History: Current grade: Name of School: Are the child s parents: married unmarried separate divorced Concerns about your child?

8 Note of protected Health Information Privacy Act Regulate Our note of privacy practice provides information about how many offices use and disclose protected health information. You have the right to review or notice before signing this consent. As provided in or notice. The terms or notice may change. You have the right to request that we restrict how protect health information about you is used or disposed for treatment, payments or health care operations. We are not required to agree restrictions, but if we do, we are bound by or agreement. By signing this form you consent to the use and disclosure of protected health information by my office treatment, payment and health care operations. You have the right to revoke this consent, in writing except where we have already made disclosures in reliance on your consent. I acknowledge receipt of privacy notice on: Date: / / Authorized party signature: Relationship to patient: