New Patient Form

New Patients
Appointment Location *

In Person Telemedicine
Patient's Full Name *

First Name Last Name
What is your Gender?

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth *

Month Day Year
Date
Phone Number *

Area Code Phone Number
Email *
example@example.com
Referring Doctor
What is your occupation?
Your Doctor *

Oren Maclean Palumbo Balekian Ober Maciag
Appointment Date *

Month Day Year
Date
Appointment Time *

: Hour Minutes AM/PM Option
What is the reason for your visit? *
Past Medical History *

NONE Asthma Cancer Cardiac disease Diabetes Heartburn/reflux Hypertension Psychiatric disorder Thyroid disease Autoimmune disease Premature birth
Are you Allergic to any medications? (if yes, please list)

No
Current Medications *
Does anyone in your family have a history of:

Asthma Nasal allergies Eczema Food Allergies Medication Allergies Bee Sting Allergy
Do you live in a:

House Apartment Duplex Condo/Townhouse
What type of flooring in your bedroom?

wall-to-wall carpeting hardwood flooring area rugs
Any pets in the house?
Do you use or have history of using tobacco? Live with smoker? Select all that apply
Do you use or have history of using tobacco? Live with smoker? Select all that apply

No/Never Yes - currently Quit/Former Smoker in house
Do you experience any of the following? Check all that apply: *

Recurrent Fevers Fatigue Weight Gain Weight Loss Blurred Vision Light Flashes Hearing Difficulty Nose Bleeds Hoarseness Neck Swelling Fluttering Heart Chest Pain Swollen Ankles Cough Wheeze Shortness of Breath Poor Exercise Tolerance Heartburn Stomach Pains Vomiting Diarrhea Pain on Urination Excessive Sweating Constant Thirst Feeling too Warm Feeling too Cold Painful/Swollen Joints Rashes Itching Depression Anxiety NONE OF THE ABOVE
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New Patients