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new patient registration

New Patient Registration

In order to minimize the time spent on your initial visit please fill out this form as
completely as possible. For your security, all Social Security Numbers will need to be filled out in our office. If you have questions about this form call us at (979)485-0571.

Patient Information
* Indicates required field

*First Name:
*Last Name:
*MI:
*Sex: M  F

*Street Address:
*City:
*State:
*Zip:

*Select One: Employed Unemployed
Retired

Employer Name:
Employer Phone:

*Phone:
Home  Work  Fax  Beeper 
Phone:
Home  Work  Fax  Beeper 
Additional Phone:

Email Address:

*Date of Birth:
*Select One: Married  Single
Divorced  Widowed
*Patient's Social Security #:



Primary Insurance Information

Same as Responsible Party    Same as Patient    Other

*Social Security # of Insured:
*Name of Insured:
*Insurance Company:
Group #:
*ID or Policy #:
*Insured's Date of Birth:
Insured's Phone:
Employer:
*Insured's Relationship to Patient:



Secondary Insurance Information

Same as Responsible Party    Same as Patient    Other

*Social Security # of Insured:
*Name of Insured:
*Insurance Company:
Group #:
*ID or Policy #:
*Insured's Date of Birth:
Insured's Phone:
Employer:
*Insured's Relationship to Patient:




Responsible Party

Same as Patient
*First Name:
*Last Name:
*MI:

*Street Address:
*City:
*State:
*Zip:

*Select One: Employed Unemployed
Retired

Employer Name:
Employer Phone:

*Phone:
Home  Work  Fax  Beeper 
Phone:
Home  Work  Fax  Beeper 

*Date of Birth:
*Select One: Married  Single
Divorced  Widowed
*Social Security #:




Emergency Contacts

*Name, address and phone # of person to contact in case of emergency (not your address or phone#):

Name, address and phone # of alternate person to contact in case of emergency (not your address or phone#):

Referring Physician: 



Allergy History
Family Doctor:
Referral Doctor:

Chief Complaint:

Associated Symptoms:
Sneezing Recurrent sore throats
Coughing Recurrent colds
Headaches Cough at night
Itching of eyes Cough on exertion
Blocking of nose Wheezing
Hoarseness Hives
Earaches Skin rash
Persistent nasal discharge           Nose bleeds
Itching of nose Diarrhea

Frequency and Duration of Attacks:

Known Causes of Attacks:

Medications Used:

Hospitalizations:

List Any Previous Allergy Testing:

Seasonal Symptoms:
Do you have trouble or is your condition worse:
In the spring           In the summer
In the fall In the winter

Climatic conditions affecting allergy problem:
Fog Rain Wind
Smog           Cold           Heat

Environmental Agents Aggravating Symptoms:
House Dust Lawns
Basements Smoke
Farm Areas           Flowers such as Mums, Zennias, Bachelor Buttons, Daisies
Animals Open Fields

Environmental Home Survey:
How old is your house?           Years

Home Type:
Apartment Farm or Country Home
Mobile Home           Home in City

Do you have any of the following:
Central Heating System with Ducts           Central Air Conditioning
Wall to Wall Carpeting Braided Rugs
Open Fireplace

Indicate the type(s) of pillows you use (foam, rubber, polyester, feathers, cotton, etc.):

Indicate your mattress type (Innerspring, foam, feather, other):

Box Springs?
Yes           No

Do you have any of the following in your bedroom?
Lined Draperies Chenille Bedspread
Upholstered Furniture Wallpaper
Jute (burlap type) Pads Rugs
Stuffed Toys or Pillows           Down Comforters or Quilts
Venetian Blinds

List all pets: (Inside)
(Outside)

List all known food intolerance:

List all known drug intolerance:

List all smokers in your environment and any smoking history:

Physical History
Are symptoms aggravated by:
Fatigue Sunlight Exposure           Cold Baths Mensturation
Tension           Exertion Hot Baths Pregnancy
Dusting Vacuuming Excitement
Soaps Dyes Animal Furs          

Infant History
Did you have any of the following:
Eczema of Skin Rash Hay Fever           Croup
Colic Vomiting Persistent Cough
Feeding Problems Asthma Stomach Aches
Frequent Ear Abscesses           Bronchitis Diarrhea

Family Allergy History:

Symptoms of Pollen Allergy:
Aggravated outdoors
Aggravated on windy days
Itching of the eyes
Aggravated on clear days
Aggravated outdoors, 7:00 to 11:00am
Improved indoors
Improved in air conditioning
Flare when going from an air conditioned room to the open air
Increased in cool air, air conditioning, or other
Not Applicable

Symptoms of Dust Allergy:
Aggravated indoors
Improved outdoors
Increased within 30 minutes after going to bed
Recur or increase each year with the return of cold weather
Nasal Symptoms with little or no itching of eyes
Aggravated with air conditioning
Aggravated when the house is being cleaned or swept
Aggravated when rugs are being cleaned
Aggravated in such dusty places as theaters, churches, grocery stores, department stores, libraries or your bedroom
Not Applicable

Symptoms of Atmospheric Mold:
Do you notice that your trouble begins or is aggravated
During prolonged periods of damp weather
When you are around grass being mowed or weeds being cut
When you are near hay or straw (as at the curcis, in a barn, near a hay stack, or on a hay ride)
When you go into an old damp house, a damp basement, a shed or cellar
When you enter a closet in which are stored old shoes, unused luggage, gloves or other leather goods
If you eat cheese, mushrooms, cantaloupe, vinegar, sauerkraut, or drink buttermilk or other fermented beverages (beer, wine, or whiskey)
When you sit in old overstuffed furniture
Have you been in a snowy climate and are you better when the snow is on the ground?
Not Applicable

Symptoms of Feathers:
Do you notice that your trouble begins or is aggravated
When lying on a feather pillow
When fluffing pillows
When using a down comforter
When you are near chickens, ducks, geese, pigeons, parrots, turkeys, canaries, or other birds
When you are around anyone who works around poultry or other fowl
Not Applicable

Symptoms of Animal Hair and Dander:
Do you notice that your trouble begins or is aggravated
When you are around any of the following animals:
Dogs Cats
Horses Goats
Rabbits           Cows
Hogs Sheep
Not Applicable

When you handle or come into contact with any of the following:
Furs Rugs
Certain articles of clothing           Dress goods
Blankets Gloves
Hats Toy animals
Brushes Not Applicable



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