New Patient Consult Form

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NEW PATIENT CONSULT FORM

Bay Shore Allergy & Asthma Specialty Practice, P.C.

Asthma, Allergy, Clinical Immunology & Pediatric Pulmonary Specialists

649 Montauk Highway

West Bay Shore, NY 11706

Louis E Guida Jr, MD FCCP Tel: (631) 665-2700

Janet Kelske, MS CPNP, ANP-C Fax: (631) 665-0290

PATIENT HISTORY

DATE: _____/_____/_____

NAME: ______DOB: _____/_____/_____ SEX: ______

ADDRESS: ______

HOME PHONE: ______CELL PHONE: ______

PRIMARY CARE PROVIDER: ______

ADDRESS: ______

TELEPHONE: ______FAX: ______

1. PLEASE DESCRIBE IN YOUR OWN WORDS THE REASON FOR YOUR VISIT:

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______

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2. HOW LONG HAS THIS BEEN A PROBLEM?

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3. ISIT PRESENT ALL YEAR ROUND OR ONLY AT CERTAIN TIMES OF THE YEAR?

4. CIRCLE ANY OF THE FOLLOWING THAT CAUSE THE PATIENT TO HAVE PROBLEMS:

DUST FEATHER PILLOWS ANIMALS MOLD/MILDEW

DAMPNESS TREES-GRASS-WEEDS INSECT SPRAY PERFUME

CIGARETTE SMOKE HAIR SPRAY EXCITEMENT/EMOTIONS NEWSPAPERS

EXERTION (RUNNING) SUMMER HEAT INDOOR HEAT COLD AIR

5. HAS THE PATIENT EXPERIENCED ANY OF THE FOLLOWING? (NOW OR IN THE PAST). CIRCLE THOSE THAT APPLY:

ASTHMA WHEEZING COUGHING SHORTNESS OF BREATH PNEUMONIA

BRONCHITIS HEARTBURN SPITTING UP ITCHING/RASHES HIVES/SWELLING

6. DOES THE PATIENT HAVE OR SUSPECT ANY FOOD ALLERGIES? IF SO, WHICH FOODS?

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7. IS THE PATIENT ALLERGIC TO ANY MEDICATIONS, SOAPS OR DETERGENTS? IF SO, PLEASE LIST THEM:

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8. LIST ANY MEDICATIONS THAT THE PATIENT IS NOW TAKING:

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______

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9. LIST ANY MEDICATIONS THAT WERE TRIED IN THE PAST THAT WERE NOT EFFECTIVE IN TREATING THE PROBLEM: (INCLUDE OVER THE COUNTER MEDICATIONS).

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10. IS THE PATIENT ABLE TO SWALLOW PILLS? YES_____ NO_____

PHARMACY NAME: ______TELEPHONE #: ______

ADDRESS: ______

______

1. DOES YOUR INSURANCE COMPANY ALLOW FOR PRESCRIPTIONS TO BE WRITTEN FOR 90 DAYS AT A TIME (MAIL AWAY) OR JUST 30 DAYS? ______

2. IS THERE ANY PAST MEDICAL HISTORY THAT WE NEED TO KNOW ABOUT?

______

______

3. HAS THE PATIENT HAD A CHEST X-RAY WITHIN THE PAST 12 MONTHS?

IF YES, WHAT WERE THE RESULTS? GOOD ______BAD ______

4. ARE THERE ANY PETS IN THE HOME? YES ______NO ______

IF YES, WHAT KIND OF PETS? ______

5. DOES THE PATIENT SMOKE? YES ______NO ______

IF YES, HOW MUCH PER DAY? ______

6. DOES ANYONE ELSE SMOKE IN THE HOME? YES ______NO ______

7. IS THERE A FAMILY HISTORY OF ALLERGY, ASTHMA, HAY FEVER, SINUS DISEASE, BRONCHITIS OR HIVES?

FAMILY MEMBER / YES / NO / TYPE OF ALLERGY
MOTHER
FATHER
SISTERS
BROTHERS
AUNTS
UNCLES
COUSINS

PSYCHOGENIC FACTORS:

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