Allergy, Asthma, Immunology of Delaware

Nasheds, PA          Maher Nashed MD

 


New patient form

 
Full Name
DOB
Social Sec. #
 

1.        “How can we help you”

 

Check all that apply

 Yes   No

1. Asthma

 

 Yes   No

2. Wheezing

 

 Yes   No

3. Shortness of breath

 

 Yes   No

4. Breathing difficulty

 Yes   No

5. Cough

 Yes   No

6. Snoring

 

 Yes   No

7. Sinus and nose symptoms: Nasal congestion, sneezing, drip in the back of the throat, runny nose, sneezing

 Yes   No

8. Frequent sinus infections

 Yes   No

9. Frequent bronchitis and Pneumonia

 Yes   No

10. Frequent colds

 Yes   No

11. Frequent ear infections/Ear pain

 Yes   No 

12. Nose bleed

 

 Yes   No

13. Headache

 Yes   No

14. Itchy, Red, Watery eyes

 Yes   No

15. Allergic reactions

 Yes   No

16. Hives

 Yes   No

17. Rash

 Yes   No

18. Itch

 Yes   No

19. Eczema

 Yes   No

20. Skin swellings

 Yes   No

21. Skin irritation/Contact Dermatitis

 Yes   No

22. Heart burn, indigestion, belly pain, acid reflux

 Yes   No

23. Nausea

 Yes   No

24. Food allergy

 Yes   No

25. Drug allergy

 Yes   No

26. Bee sting allergy

 Yes   No

27. Other insect allergy

 

 

Other issues: If you have any other issues, please write

 

 

3.  Other general health issues. Do you get any of these items? Just click yes or no.

 Yes No

Weight loss without reason

 Yes No

Fever for a long time

 Yes No

Medications changes

 Yes No

Ear pain or clogged

 Yes No

Eye pain

 Yes No

Swollen glands

 Yes No

Neck mass

 Yes No

Difficult breathing when lying down

 Yes No

High blood pressure

 Yes No

Diabetes or high sugar in the blood.

 Yes No

Heart attack, bypass surgery in the heart, heart murmur. leg swelling

 Yes No

Joints pain, swelling, stiffness

 Yes No

Seizures, stroke

 Yes No

Trouble walking

 Yes No

Depression

 Yes No

Anxiety

 Yes No

Panic attacks

 Yes No

Inability to concentrate

 Yes No

Thyroid problems, hard to tolerate cold or hot

 Yes No

Anemia / low iron in the blood

 

4.  Please mention any diseases that are already diagnosed by other health professional

 

5. Drug allergy: Please mention the medications you are allergic to, what reactions you had and when you had the reaction to the best of your memory.

6. When was the last time you had?

The pneumonia shot

The tetanus shot

 

7. Family history. Does your family has history of  (Click yes or no)

 Yes No

Allergy

 Yes No

Diabetes

 Yes No

Cancer

 Yes No

Autoimmune disease

 Yes No Asthma
 Yes No Early death

 

8. Personal history

Have you ever smoked?  Yes   No   If yes, how long you smoked and how many packs per day

Do you drink alcoholic beverage If yes, how often and how much do you drink

Do you take other recreational drugs

 

9. Home environment

Do you have Cats

Do you have Dogs

Are you in contact with other animals if yes, what are they

Any smokers around you (yes/No)

How old is your home

Is your home close to the river (Yes/no) or in the city (Yes/no)

Do you have central air (yes/No)

What type of home it is

do you have well water (Yes/no)

 

10. Please list your medications


11. Please upload any files you want to include with your patient record.


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