New Patient Historykmattikalli@gmail.com2021-02-13T10:30:13-05:00 Choose an office *Please select an office…Allergist Alexandria, VAAllergist Annapolis, MDAllergist Arlington, VAAllergist Baltimore, MD at PikesvilleAllergist Bel Air, MDAllergist Bowie, MDAllergist Chambersburg, PAAllergist Columbia (Little Patuxent Pkwy), MDAllergist Columbia, MDAllergist Dundalk, MDAllergist Easton, MDAllergist Ellicott City, MDAllergist Fairfax, VAAllergist Falls Church, VAAllergist Frederick, MDAllergist Germantown, MDAllergist Glenn Dale, MDAllergist Greenbelt, MDAllergist Hagerstown, MDAllergist North Bethesda, MDAllergist Owings Mills, MDAllergist Reston, VAAllergist Shady Grove, MDAllergist Silver Spring, MDAllergist Towson, MDAllergist Washington, DC at DuPont CircleAllergist Washington, DC at Foxhall VillageAllergist Westminster, MDAllergist Woodbridge, VAPatient First Name *DOB Referred by How did you hear about us? Patient Last Name *Primary Care Physician Pharmacy Reason for today’s visit Current Medications (dose & frequency) Medication Allergies/Sensitivities (list reaction) Food Allergies/Sensitivities (list reaction) Symptoms Ear, Nose, Throat runny nosesneezingnasal congestionpost nasal dripsore throatsinus pressure/painthroat swellingear achesEyes itchywaterydryredswollendrainagedark circlespainRespiratory coughshortness of breathwheezingchest tightnessSkin symptoms hivesitchingrashdrynesseczemaStomach upset stomachrefluxnauseavomitingdiarrheaconstipationabdominal painHead migraineschronic headachesvertigodizzinessPast Allergy & Asthma History Previous skin tests/blood tests/allergy shots? Any adverse reactions to vaccinations? YesNoVaccinations up to date? Select an Option…YesNoAsthma diagnosis? YesNoHow many years ago was this? Use of an inhaler or nebulizer? YesNoStung by a bee? YesNoAny adverse reaction? If yes, please describe reaction Last chest x-ray, and the results? Performed a Pulmonary Function Test? YesNoMedical History: Emergency Room Visits (date and reason) Days of school or work missed per year History of Cancer BreastBrainLungPancreaticOvarianProstateStomachLiverSkinCervicalEsophagealCardiac StrokeHypertensionPalpitationsMurmurPacemakerEyes GlassesContact lensesGlaucomaBlindnessCataractsEye DiseaseEars Hearing aidsHearing lossChronic ear infectionsNose Nasal polypsNosebleedsAllergic rhinitisChronis sinusitisSkin RashEczemaAcneHair lossNail disordersMusculoskeletal ArthritisOsteoporosisChronic back painEndocrine DiabetesThyroid conditionAutoimmune disorderKidney diseaseRenal diseaseAddison’s diseaseSclerodermaLupusGastrointestinal RefluxEsophagitisHerniaUlcerPolypsGallbladderCrohn’s DiseaseIrritable Bowel SyndromeUrinary/Reproductive Breast DiseaseProstate DiseaseChildbirth historyRespiratory AsthmaCOPDChronic bronchitisTuberculosisPneumoniaEmphysemaSleep ApneaNeurological EpilepsySeizuresChronic headachesMigrainesMemory lossStrokePsych/Social DepressionSuicide AttemptAnxietyBipolarOCDInsomniaSurgical History List date & procedure(s) Family History (check all that apply) Father AsthmaAllergiesImmune DisorderBrother AsthmaAllergiesImmune DisorderPaternal GF AsthmaAllergiesImmune DisorderMaternal GF AsthmaAllergiesImmune DisorderMother AsthmaAllergiesImmune DisorderSister AsthmaAllergiesImmune DisorderPaternal GM AsthmaAllergiesImmune DisorderMaternal GM AsthmaAllergiesImmune DisorderSocial History Occupation Hobbies Where Employed Number of children Marital Status SingleMarriedDivorcedSeparatedWidowedOtherPrimary Residence Select an options…One Home2 or more HomesTobacco Use Select an options…YesNoHow much for how long? Tobacco Exposure Select an options…YesNoAlcohol Use Select an options…YesNoDrug Dependency Select an options…YesNoPets Cat Number How long owned Bathed? Symptoms Age Kept where Bedroom Access? Dog Number How long owned Bathed? Symptoms Age Kept where Bedroom Access? Bird Number How long owned Bathed? Symptoms Age Kept where? Bedroom Access? Rabbit, Hamster & Guinea Pig (please note which) Number How long owned? Bathed? Symptoms Age Kept Where? Bedroom Access? Reptile Number How long owned Bathed? Symptoms Age Kept where? Bedroom Access? Other Number How long owned Bathed? Symptoms Age Kept where? Bedroom Access? Environmental History Type of Home Select an Option…Single FamilyTown HouseMobile HomeApartmentOtherHome Age Heat/Cooling System Select an Option…Forced Hot AirCentral AirWindow Air ConditionerRadiatorsDehumidifier Select an Option…YesNoBedding Select an Option…Feather PillowsFoam PillowsStandard BedWater BedPlants Select an Option…YesNoLocation of laundry room Structure Select an Option…Wood FrameBrickLength of Residency Foundation Select an Option…BasementCrawl SpaceSlabPatient’s Bedroom Select an Option…CarpetHardwoodTileCurtainsHypoallergenic Bedding Select an Option…YesNoNumber and location of plants Outdoor clothes line Select an Option…YesNoAdditional Comments WebsiteSubmit
