Allergy, Asthma, Immunology of Delaware
Nasheds, PA          Maher Nashed MD

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New Patient Information

Insurance Information

  
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New Patient Information

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Nasheds PA                                                 New Patient Information
Patient Name: __________________________________________________________________
Present occupation (describe): ________________________________Duration:_____________
Past occupation (describe):___________________________________Duration:_____________
Main problems now: ________________________________________________________________________
______________________________________________________________________________
Please give us more details about your problems

Breathing Problems/Asthma:
How long do you have it? _________ Is it year round or seasonal? ________________________
Most recent episode:_________ How long it did last?________ Treatment used:____________
Things bring it on/make it worse:______________________ Things make it better:___________
Is it the same, worse, or better since started? ________How often you get them per week or month? ______________
How many of them are at night? _____________ is it worse by day or by night? __________ How long the symptoms last? ________
What do you feel? ___________________________________ Do you get wheezing when you get the air in or out? __________
How many ER visits or hospitalizations you had? __________ Your breathing medications: _________________________________  How often you use? The rescue medication per week or month: _________________________
How often you use the the other medications per week or month: ________________________________

Sinus Infections:
How long do you have them? __________ How many infections per year? _______________ How long each last? _________
What was the treatment? ______________________ Did you have a sinus CAT scan? ________ Did you had sinus surgery? _______ How many? __________ When was the last one? __________________
What are your symptoms when you have a sinus infection? __________________________________________________

Nasal Congestion/Stuffy Nose:
How long do you have it? _______ Is it year round or seasonal? ____________ is it daily or on/off? _______
How long it last when you have it? _________ Is it one side or both? ________ Things make it worse __________________________ Things make it better: _______________ is it the same, worse, or better since started? _______________________________
What are your allergy medications: _________________________________________________

Sneezing:
How long do you have it? _______ Is it year round or seasonal? __________________________   How long it last? ______
Things bring it on: __________________________________________
Is it the same, worse, or better since started? _____________________________

Cough:
 How long do you have it? ______ Is it year round or seasonal? ______ How often do you cough? __________
Things make it worse: ___________________________________________ Things make it better: ____________________
Is it dry or wet? _______ Is it worse by day or by night? ______Is it the same, worse, or better since started? _______
Do you cough with activities? ______ Your cough medications: __________________________________________

Itchy and Watery eyes:
How long do you have it? ____________ Is it year round or seasonal? _____________ How long it last? ________
Is it one side or both? ____________ Things make it worse: _______________ Things make it better: _______________________
 Is it the same, worse, or better since started? _____ Your Eye medications: ____________________________________________

Hives and Rash:
How long do you have it? ______ Is it hives or rash? ______ Is it year round or seasonal? ____ How many times you had it? _______ How long it last? ______________ Where hives/rash started? ________ Where did it go from there? ______________________ Things make it worse:__________________________ Things make it better:____________________________
Do you have any pictures?__________ What it looks like? ______________________________
Is it the same, worse, or better since started? ________________________________________
Your rash or itching medications: __________________________________________________

Post Nasal Drip or Clearing the throat:
How long do you have it?_________ Is it year round or seasonal?_____  How long it last when you have it? Minutes______ Hours_____ Days_______ Months_____ All the time_____ Things make it worse:___________________
Things make it better:____________________________ is it the same, worse, or better since started?_______
Is it worse by day time or by night?_____ Does exercise affect it:________
Medications used for it:_______________________________

Heart Burn:
How long do you have it? ______ Is it year round or seasonal?______ How often you get it?_____ How long it last?__________ Where do you feel it?__________ Things make it better:____________________
Things make it worse:_________________________________ Is it the same, worse, or better since started?_________
What other symptoms do you feel with it?___________________________________ When is the worse time?_______________

Snoring:
How long do you have it?______ Do you have it every night?_________ Is it worse on one side?_____
Things make it worse :________________________ Is it the same, worse, or better since started:__________
Witnessed stop breathing at night?_______ Witnesses stop breathing duration:_________________________
How to you feel in the morning?__________________

Nose bleeds:
How long do you have it? _____ Is it year round or seasonal? ________How long it last?______ One side or both?________
Things make it worse:_____________________________________ Things make it better:__________________
Is it the same, worse, or better since started?_____ Have you had any trauma to your nose?_______
Do you have bleeding problem?____________

Frequent Infections:
How many colds/bronchitis/sinusitis/ear infections/other infections you get per year? _______
How many years do you have them?_______ How long each last? _______________
How many pneumonia you had in your life time? ______________________________________________
How these infections were treated? ________________________________________________
Please, bring with you any blood work results you have. 

Headache:
How long do you have it?______ Is it year round or seasonal?__________ How many times per week/month? ____________
How long it last?________  Where is the headache?___________ Things make it worse:____________________________
Things make it better:______________ Is it the same, worse, or better since started?_________________
Have you had any trauma to your head?_______  Did you have CT of the head? ________When?_______________________
Your headache medications:_______________________________________________________
 
 
Ear Infections/Ear pain:
How long do you have it? ____ Is it year round or seasonal:____________ How many times per year?_____________
How long each last?_________ Is it the same, worse, or better since started? __________
Other symptoms you feel with it: _________________________________

Bee Sting Allergy:
When did it start?__________________ How many stings you had at the first time?_________
Where was the sting? __________what were the symptoms? ___________________________
What was the treatment? ________________________________________________________  Do you have an Epipen?_____
Is it expired? _____Have you been stung after the first one?____ If yes, How many times?_____
Describe the reactions and their treatments: ______________________________________________________________________________ ______________________________________________________________________________

Drug Allergy:
Please list medications names, when you had the reaction and what was the reaction.         
Please use one line for each medication, thanks. ______________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are other diseases you might have/had? _______________________________________

What are other things you are allergic to not mention above like food, chemicals or other drugs?
Please, write each on a separate line, when it happened and the reaction to it. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The date of the last tetanus and pneumonia vaccines, if known: ________________________

What are the health conditions that run in your family?
Check beside the one applicable to you: Allergy_____ Asthma____ Cancer_______ Diabetes __ High Blood pressure_____ Others__________________________________________________
 
 
Home Environment:
How old is your home? ______ Is it?  Rural _________suburban ________ city_____________ Is your House? Single family____ Apartment _____ Mobile _____ Townhouse _____ Others:___ Do you have: Public water _____Well water_____
Natural gas for heating or cooking_________ Central air/heat________ Window air condition_______ Electric heat_____
Fire Place________  Cats _____Dogs______ Please, write other animals inside or outside the house and their number if possible ______________________________ Carpet in the bedrooms?: __________ Living room:_________
Are you renovating/repairing your home?________________________
Smoking: Do you or did you smoke? ____ If yes, for how many years in your life time did you smoke? _______
What is the average packs per day during these years?___________________  
Any smoking inside or outside the house:____________________________________________

Please list all other Medications, including vitamins, you take but did not mention above. Please write the names, dose and for how long you have been taking them. You can also bring the list of medications on a paper if they are many. You can write any other concerns you might have, Thanks. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________