New Patient Intake Form

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If you have any questions, please feel free to reach out

Phone: (603) 332-7774
Fax: 603-332-7775
Email: aacenternh@hushmail.com
Website: aacenternh.wordpress.com

Patient Information

First name

Last name

Date of birth

Gender/Gender Identity

Address

City

State

Zip Code

Email address

Cell phone number

Home phone number

Medical History

Do you currently have a primary care provider?

Yes No

If yes, please list your provider's name, phone number, and office address.

Pharmacy name and address you use

Are you currently taking any allergy medication?

Yes No

Please specify below which allergy medications you are taking if you are taking any.

Do you have any known allergies to medications? If so, please specify below.

Please provide a brief description below on what is bringing you in to see us.

Insurance Information

Add a secondary insurance

Emergency Contact Information

Preferred Emergency Contact

Phone Number

Relation To You

Medical History Questionnaire

This questionnaire will help us determine what is responsible for your symptoms. Please fill out and answer the questions below to the best to your ability.

I now have or have had in the past (Check all that apply)

Hay fever (Allergic nose symptoms)

Rashes

Asthma

None of the above

My nose is often itchy and watery.

Yes

At certain times, my eyes get red, itchy and watery

Yes

The back of throat is sometimes itchy.

Yes

My nose is always stuffy.

Yes

I frequently sneeze.

Yes

I seem to have one sore throat after another

Yes

I frequently get sinus infections.

Yes

If I am emotionally excited, tense, or tired, my symptoms seem worse.

Yes

My allergies seem to be worse when the furnace is turned on for the first time each fall.

Yes

House dust seems to make my conditions worse.

Yes

I seem to cough a lot at night.

Yes

Exercise or laughter often makes me cough.

Yes

I sometimes wheeze during or after hard play or work.

Yes

There are wet/damp/moldy areas in my house.

Yes

I smoke cigarettes.

Yes

If you answered yes, how many cigarettes do you smoke a day and for how long have you been smoking for?

Changes in temperature usually make my symptoms worse.

Yes

I have a cat or dog in my household.

Yes

If answered yes, how many animals?

The following foods have disagreed with me in the past or present:

Milk

Wheat

Chocolate

Egg

Other

None

If you answered "other" to the question above, please explain:

I seem to have a lot of (Check all that apply)

Headaches

Stomaches

None of the above

The very first allergic reaction that you can remember occurred when? *Please state where you were, what you were doing & season the year*

The following members of my family also have allergies/allergy symptoms:

The following medications have seem to have made my allergies better in the past:

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New Patient Intake Form

Contact Us

Patient Information

Medical History

Insurance Information

Emergency Contact Information

Medical History Questionnaire

Contact Us

Allergy and Asthma Center