Online Patient Registration

Please fill out the form below with all the relevant information. After you have completed the form, it will be encrypted and sent to Allergy & Asthma Specialists of Virginia, P.C. electronically via e-mail.

New Patient Questionaire

Name: Date:
1. Did a physician recommend that you see an Allergist?
If so, who?
2. What problem(s) have you been referred for or can we help you solve?
3. Do you have any drug allergies?:
If so, please list drugs and interactions:
4. Are you on any medications?:
        If so, please list drugs and dosages:
Medication Name Dose How many times a day? Daily or as needed?
5. Do you have a history of:
a. Asthma, wheezing or recurrent bronchitis?
b. Previous albuterol use?
c. Allergic rhinitis or hay fever?
d. Eczema?
e. Hives or swelling?
f. Sinusitis?
g. Allergy to insect stings?
h. Food allergy?
6. Do you have any other medical problems?
If so, please list them:
7. Have you had any surgeries?
If so, please list them:
8. Do any of these problems run in your FAMILY? (If so, please type which family member to the right):
a. Nasal allergies?
b. Asthma?
c. Autoimmune disorders? (Ex: Lupus, MS, RA)
d. Blood clots?
e. Bronchitis?
f. Heart disease?
g. Diabetes?
h. Difficulty swallowing?
i. Eczema?
j. Food allergy?
k. Heartburn/GERD?
l. Hypertension?
m. Immune system problems?
n. Insect allergy?
o. Migraines?
p. Nasal polyps?
q. Thinning of the bones?
r. Sinusitis?
s. Sleep Apnea/Snoring?
t. Thyroid problems?
u. Hives or swelling?
v. Cancer?
Please list any other medical problems that run in your family:
9. Are you employed?
If so, where?
10. In your home, do you have:
1. Allergy covers for pillows or mattress?
2. Fans?
3. Humidifiers?
4. Carpets or rugs?
5. Allergy air filters?
6. Air purifiers?
7. Feather or down bedding?
11. What type of residence do you live in?
What year was it built?
13. At your work or home, do you notice insects? (Ex: cockroaches, lady bugs, etc.)
14. Who lives at home with you? (The patient)
15. At your home or work, do you have water damage or mold?
16. Do you have pets?
If so, please list them:
17. At your home or work, do you notice rodents?
If so, please list them (Ex. mice, rats, etc.):
18. Are you in school/daycare?
19. Do you smoke or did you used to smoke?
20. Does anyone else who lives with you smoke?
21. Do you have problems with: (Check all that apply)
Please Click Here to return to
© 2011 Allergy and Asthma Specialists of Virginia. All rights reserved.