New Patient Registration and Medical History. Address City State Zip code

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Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm New Patient Registratin and Medical Histry Name Tday s date Address City State Zip cde Hme phne Cell phne Email Birth date Sex M/F Marital status Scial security # Occupatin & emplyer/schl Race/Ethnicity Referring physician Preferred pharmacy name & phne # Primary care physician Mail rder pharmacy What is the reasn fr yur visit tday? If yu have been given a diagnsis by anther physician, please specify it here, as well as the diagnsis cde if knwn. PAYMENT AND INSURANCE INFORMATION Please nte that we will need t cpy yur pht ID and insurance card. Primary Insurance Member ID# Grup name Grup/Plan # Plicy hlder/subscriber name Relatinship t patient Plicy hlder/subscriber birth date Phne number Plicy hlder/subscriber address D yu have separate pharmacy cverage? Yes / N If yes, please prvide the ID # Secndary Insurance (if applicable) Member ID# Grup name Grup/Plan # Plicy hlder/subscriber name Relatinship t patient Birth date Financially respnsible party If the patient is a minr, t whm shuld bills be sent? Name Relatinship t patient Date f birth Phne number Address City State Zip cde Page 1 f 6

Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm ALLERGY AND ASTHMA HISTORY Date f birth Yes N If yes, please answer the questins belw: Has the patient ever been diagnsed with asthma? At what age? Any hspitalizatins fr asthma? When? Any ER visits fr asthma? When? Any ral sterids (prednisne) fr asthma? When? Has the patient ever had allergy testing befre? When? By whm? Ever n allergy shts? Has the patient ever been diagnsed with eczema? Evaluated by a dermatlgist? adverse reactins t fds? adverse reactins t medicatins? adverse reactins t bee stings? adverse reactins t latex? Page 2 f 6

Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm PAST MEDICAL HISTORY Date f birth Is the patient pregnant? Yes N (Please circle yur respnse) Please indicate if the patient has, r is being treated fr, any f the fllwing: Yes N Yes N Yes N Cataracts Thyrid disease Sleep apnea Glaucma Lupus GERD (heartburn) Osteprsis Rheumatid arthritis Headache/Migraine Anemia Celiac disease Nasal plyps Diabetes Psriasis Sinus infectins Heart disease Anxiety Ear infectins High bld pressure Depressin Pneumnia High chlesterl Cancer (specify type) COPD (emphysema) Des the patient have any ther medical prblems? Please specify. HOSPITALIZATION HISTORY Please list all hspitalizatins the patient has had, with the year and the reasn: SURGICAL HISTORY Please indicate if the patient has had any f the fllwing prcedures, and specify the year: Yes N When Yes N When Tnsillectmy Adenidectmy Ear tubes Sinus surgery Nasal surgery Nasal plyp remval any ther surgery? If yes, please specify the prcedure and year it was perfrmed. Page 3 f 6

Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm FAMILY HISTORY Date f birth Have any f the patient s bld relatives been diagnsed with any f these cnditins? If yes, please specify wh: Yes N Wh? Yes N Wh? Asthma Allergic rhinitis/hay fever Eczema Fd allergies Celiac disease Urticaria (hives) Angiedema (swelling) COPD/Emphysema Osteprsis Cataracts Glaucma Thyrid disease Lupus Rheumatid arthritis Cancer (type?) Diabetes Hypertensin High chlesterl MEDICATIONS Please list the patient s current medicatins and dses. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Medicatin Dse Frequency Page 4 f 6

Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm Date f birth ENVIRONMENTAL HISTORY Yes N If yes, please answer: Are there any pets in the patient s hme, r is there any ther expsure t animals? What kind, and hw many? Has the patient ever smked? Hw much, and fr hw lng? Des the patient want t quit? Des anyne smke arund the patient? Des the patient g t schl r daycare (children)? What is the patient s ccupatin? Is there anything the patient is expsed t that yu believe triggers symptms? Any seasn when they get wrse? IMMUNIZATIONS If the patient is age 18 years r under, is he/she up t date n all childhd vaccines? Yes N When was the patient s last flu sht? Please give the date. Has the patient ever had a pneumnia vaccine? Yes N If yes, which ne, and when? Pneumvax date Prevnar date Page 5 f 6

Wexfrd Allergy, Asthma & Immunlgy, LLC Phne (724)719-2441 / Fax (724)719-2451 100 Bradfrd Rad, Suite 410, Wexfrd, PA 15090 www.wexfrdallergy.cm REVIEW OF SYSTEMS Is the patient currently experiencing any f the fllwing symptms? Date f birth GENERAL MOUTH/THROAT MUSCULOSKELETAL Fever Chills Fatigue Itchy thrat Sre thrat Frequent thrat clearing Harseness Muscle pain Jint pain Jint stiffness Jint swelling Jint redness/warmth EYES NECK SKIN Red Watery Itchy Swelling Lumps Rash Hives Itching Flaking/peeling Swelling Redness/flushing EARS RESPIRATORY NEUROLOGIC Pain Fullness/ppping Itching Cugh Wheeze Difficulty breathing Chest tightness Truble with exercise Headache Dizziness/vertig NOSE GASTROINTESTINAL PSYCHIATRIC Stuffy/cngested Itchy Runny Sneezing Lss f sense f smell Pst-nasal drip Sinus pressure Nsebleeds Stmach pain Heartburn Nausea Vmiting Diarrhea Cnstipatin Stressrs Sleep disturbance Page 6 f 6

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