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					The Allergy & Clinical Immunology Center
230 North Maple Ave, Marlton, NJ
New Patient Questionaire

                                                                     New Patient Questionaire
                       (We thank you for completing this form prior to your visit.
          Otherwise, one extra hour before your appointment time is needed to complete this form)
Name:                                                       Date of Birth:                                Appointment Date:                                  (Please Print)

What is the reason for your today’s visit?
Briefly describe the reason for your visit to The Allergy & Clinical Immunology Center and what you/your referral physician hope to accomplish after this visit;
(A note from your referral physician in regards the purpose of today’s visit would be much appreciated)
2. _______________________________________________________________________________________________________________________________
What symptoms are bothering you the most?
1. _________________________________________________________________________________________________________________________________
Are you having pain related to this visit?                      NO____ ; YES_____
      1. Location___________________________________________________________________________________________________________________
      2. Describe the pain_________________________________________________________________Rate the pain 1 2 3 4 5 6 7 8 9 10
      3. What makes it better _________________________________________________________________________________________________________
      4. What makes it worse__________________________________________________________________________________________________________

What diagnoses have you been given by your doctor(s) or that you strongly suspect? (Please check ALL that apply.)
                            Diagnosis                       Date of diagnosis                         Past Medical and Surgical History                        Date of diagnosis
         Rhinitis/ “Hay Fever”                                                         Hypertention/Diabetes/Hyperlipidemia
         Sinusitis                                                                     Heart Disease/Heart attack
         Asthma                                                                        Peptic ulcer/Acid reflux esophagitis
         Food allergy (also complete Table A if this is                                Hepatitis or any liver disease
         the reason for your today’s visit)
         Drug allergy (also complete Table B if this is                                Gluten/wheat sensitivity or Lactose intolerance
         the reason for your today’s visit)
         Stinging Insect allergy                                                       Chronic bronchitis/ COPD/ Emphysema/sleep apnea
         Latex allergy                                                                 Cataracts/Glaucoma
         Eczema/atopic dermatitis                                                      Thyroid disease
         Urticaria/hives                                                               Depression
         Swelling                                                                      Other

What symptoms do you currently have? (Please check ALL that apply)
    Eye itching/redness/watering              Nasal discharge                    Wheezing                           Heartburn/Reflux symptoms
    Nasal congestion                          Facial pain                        Shortness of breath                Skin itching
    Runny nose                                Frequent headaches                 Chest tightness                    Dry skin
    Sneezing                                  Smell impaired                     Limitation of exercise             Skin rash
    Post nasal drainage                       Sleep interference                 Hoarseness                         Swelling        location _______________________
    Other                                     Other                              Cough                              Frequency (____________times/week, month, or year)

Are your symptoms worse consistently at certain times of year?
Seasonal Incidence (indicate relative intensity, +, ++, +++, ++++)
                                                  Early Spring           Late Spring           Mid Summer           Early Fall           Late Fall          Winter
Symptom (in order          Year long back-        Mar/Apr                May/June              July/early Aug       Aug/Sept             Oct/Nov            Dec-Feb
of severity)               ground symptoms

                                                                                                                                         New Patient Questionaire.09.09.Page 1 of 3
The Allergy & Clinical Immunology Center
230 North Maple Ave, Marlton, NJ
New Patient Questionaire

Factors that obviously aggravate your symptoms: (check ALL that apply)
          Pollens                      Tobacco smoke                          stress                               Foods _____________________________________________
          Molds                        Odors/perfumes                         Exercise
          Dust                         Dry/Cold Air or Heat humidity          Head cold or infection               Drugs (aspirin, ibuprofen, naproxen, others) ________________

Have you been previously tested for any form of allergy?
             Skin or Blood Test             Ordering Physician               Performing laboratory                Testing Date (mon/yr)               Testing Result (copy preferred)


Have you been previously treated for any of the above condition?
    Yes        With allergy           Prescribed by                Injected By                             Total Duration _____              Reasons for stopping
               injections             Dr.__________                Place__________Person ______            From ____ to _______              _________________
    Yes        With                   OTC medications              Effectiveness (for each drug)           Prescribed medications            Effectiveness (for each drug)
               medications            (Date taken__________)       !) Yes _____% improvement of your       (Date taken_____________)         Yes _____% improvement of your symptoms
                                                                   symptoms;                                                                 No _____duration of taking medications (days
                                                                   !!) No _____duration of taking                                            or weeks)
                                                                   medications (days or weeks)                                               !) ___ %_____; !!) ________________
                                      a)__________________         !) ___ %_____; !!) __________           a)_____________________
                                                                                                                                             !) ___ %_____; !!) _______________
                                      b)__________________         !) ___ %_____; !!) _________            b)____________________
                                                                                                                                             !) ___ %_____; !!) _______________
                                      c)_________________          !) ___ %_____; !!) __________           c)____________________
                                                                                                                                             !) ___ %_____; !!) _______________
                                      d) _________________         !) ___ %_____; !!) __________           d)____________________


 How many days or weeks per year do you miss from work or school due to above condition?
 _____________during seasons;                       ____________off seasons ;                               ___________ whole year

Please list your current oral and inhaled medications; including medication name, dose, and the number of times per day you take it and whether you take it regularly
or only “as needed. If “as needed”, how many % time you take it during the season?
                                                                   Tablet        # of Times            Regular          Only “As
          Oral Medications                                        Strength        Per Day               Use             Needed”                              Comments
                                                                                                                    (% time taking it)

Family History (please check the one who has atopy history including rhinitis/Hay fever, asthma or allergic dermatitis in your family)
               Ages           Relationship to you        Living         Deceased          In Good health         Health Problems                        Atopy History (be specific if Yes)

Environmental Survey (Please circle or check ALL that apply)
    Cities/states where you have resided in from birth to present                Radiator/baseboard heat            Water damage                           Occupation:
    (including dates)                                                                                                                                      Place________ Date________
    Live in single family House/Condo/townhouse/                                 Hot air heat                       Visible mold growth                     Work environment
    apartment/mobile home
    For how long?____________                                                    Central A/C                        Indoor animal exposure                  Carpeted
                                                                                                                                          New Patient Questionaire.09.09.Page 2 of 3
The Allergy & Clinical Immunology Center
230 North Maple Ave, Marlton, NJ
New Patient Questionaire

       How old is structure?_______                                              Window/wall A/C unit                  Cat – in bedroom Y / N             A/C: Central ___Window___
       Wall to wall carpeting                                                    Feather pillow                        Dog – in bedroom Y / N             Water damage/mold
       Cockroaches                                                               Feather comforter                    Humidifier                          Irritants/chemicals
       Mice                                                                      Indoor cigarette smoke                                                    Smoke

Personal History/ Social History
    Never smoking:                                                                 Alcoholic Beverages
    Current smoking: cigs/day:
    Previous smoking                  Ave pack/day start and stop year
    Pipes                                                                          Other illicits

Review of Symptoms (please circle that ALL apply)

Constitutional                Unexplained weight loss or weight gain; night sweats; fatigue/malaise/lethargy; prolonged fever or chills; none;

EYES                          Watery/itchy eyes; use of eye glasses or contacts; none
ENT                           Hearing loss; ear ache; frequent infections (_____times per year); runny nose; stuffy nose; frequent sneezing; postnasal drip; frequent nose bleeding; sinus
                              infections (_____times per year); mouth ulcers; hoarseness; tongue or throat swelling; difficulty in swallowing; none
Respiratory                   Breathlessness; wheezing; chest tightness; cough (productive or non-productive); bloody sputum; abnormal Chest X-ray (last Chest X-ray _______); TB
                              (last skin test for TB/PPD or last BCG vaccine________); asthma (last flu vaccine_______); bronchitis/Pneumonias (_____times per year and last
                              peumovax vaccine_______); none
Cardiovascular                Chest pain; shortness of breath; exercise tolerance; PND; orthopnoea; edema; palpitations; faintness or loss of consciousness; heart attack; Rheumatic
                              fever; none
Gastrointestinal              Heart burn; difficulty swallowing; indigestion; abdominal pain; nausea/vomiting, or haematemesis; jaundice; diarrhea; constipation; bowel habit changes;
                              bloody stool; none
Genitourinary                 Pain in urination; Frequent urination; difficulty in urination; incontinenece ; kidney stones ; none
Heme                          Anemia; easy bruising ; abnormal bleeding; none
Musculoskeletal               Joint pain; joint stiffness; Joint swelling; muscle pain; none
Skin                          Frequent hives; rash; itching; none
Neurological                  Any changes in sight, smell, hearing and taste; seizures ; fainting; headache; pins and needles or numbness; limb weakness; poor balance; speech
                              problems; sphincter disturbance; loss of memory; none
Psychiatric                   Mood changes; psychiatric disorders; behavioral changes; sleep patterns; none

Drug Adverse Reactions including Drug allergy                                             If None, please CHECK HERE.                □
 Name of Medication               Nature of Adverse Reaction including allergy                                          Comments including when it occurred

Food Adverse Reactions including Food allergy                                             If None, please CHECK HERE.                □
                 Name of Foods                          Nature of Adverse Reaction including Allergy                                 Comments including when it occurred

________________________________                                                                    _________________________________
Your signature and date                                                                             Physician’s signature and date
                                                                                                                                           New Patient Questionaire.09.09.Page 3 of 3

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