New Patient Questionnaire (Form 2 of 5)

Name*
Date of Birth*

ex. 01/12/1960
What is the reason for your appointment? When did your symptoms start?*
How did you find out about us?
If referred by a Physician, please provide their name
If you have a Primary Care Physician (PCP), please provide their name
Primary Care Physician (PCP) Address
Street Address Address Line 2 City State ZIP Code
Preferred Pharmacy Name
Preferred Pharmacy Address
Street Address Address Line 2 City State ZIP Code

Please list any medical issues you have ever been treated for, including ENT issues like allergies.*
Is there anything else you take medicines for?*
Please list any surgeries or procedures (including tonsillectomy and ear tubes) you have ever had and when they were performed.*
Surgery Year
Please list any prescription or over the counter medications, herbs, or supplements that you take.*
Medication Dose How Often Last Taken
Please list any medication allergies and your reactions to them.*

Please describe any smoking or smokeless tobacco use at any time in your life. Please include vaping. If you have never used tobacco, please write "Never."*
Type of Tobacco How much per day (ex. number of cigarettes) Year Begun Year Quit
Please describe any alcohol use at any time in your life.*
Type of Alcohol How much per day (ex. glasses of wine) Year Begun Year Quit
Please list any drug use at any time in your life.*
Type of Drugs How Often (ex. times per week) Year Begun Year Quit

Have you ever had any allergy testing? If so, when?*
What were you allergic to?*
Have you ever taken allergy shots?*
- Yes
- No
What year did you begin taking allergy shots?*
Were the allergy shots helpful?*
- Yes
- No
Have you or any family members had any problems with general anesthesia?*
- Yes
- No
If yes, please describe what type of problems and to whom they occurred.*

Type of Tobacco	How much per day (ex. number of cigarettes)	Year Begun	Year Quit

Type of Alcohol	How much per day (ex. glasses of wine)	Year Begun	Year Quit

Type of Drugs	How Often (ex. times per week)	Year Begun	Year Quit

Surgery	Year

Medication	Dose	How Often	Last Taken