New Patient Information and Symptom Questionnaire

Throat, sinus, breathing and cough. It takes about 10 minutes. Fields marked * are required.

Do not use this form for an emergency. Call 911 now if you have:

Trouble breathing at rest, or can only say a few words at a time
Lips or fingertips turning blue or gray, or your rescue inhaler is not helping
Drooling, can't swallow your saliva, or can't open your mouth fully
Swelling or redness around the eye, vision changes, severe headache with stiff neck, or confusion

One of your answers can be a sign of a serious problem. If you are having it right now, stop and call 911 or go to the nearest emergency room.

1. About you

Last name First name Middle initial Date of birth Age

What should we call you?

First nameLast name

Street address City State Zip code Home phone Cell phone Work phone Email Work zip code

How do you get here?

MetroTaxiWalkDrive

Employer How long employed there Family doctor's name Preferred pharmacy If filling out for someone else: your name and relationship

Emergency contact

Name Relationship Phone

How did you hear about us?

Newspaper (name) Magazine (name) Friend or family (name) Other

2. Why you are here today

What is your main problem today? When did it start? (date or number of days) Highest temperature, if measured (°F)

How did it start?

Suddenly (within hours)Slowly (over days)

Since it started, are you:

Getting betterStaying the sameGetting worse

Did you start to feel better, then get worse again?

YesNo

Have you had this problem before? If yes, when? What have you tried for it? (medicines, home remedies)

3. Symptom checklist

In the past 2 weeks, have you had any of the following?

Symptom	Yes	No

If you are coughing up mucus, what color is it?

4. Breathing and asthma history

Have you ever been told you have asthma?

YesNoNot sure

5. Exposures and health history

Question	Yes	No

Medicines you take now (include inhalers, vitamins, over-the-counter) Allergies to medicines (and what happens) Other health conditions

Flu vaccine this season?

YesNo

COVID vaccine this season?

YesNo

6. Privacy notice and signature

Privacy notice: We take your privacy and the privacy of our patients very seriously. You agree not to audio record, video record, or take pictures of other patients, staff, physicians, or our facilities. You unconditionally agree not to disclose information about other patients, staff, physicians, or facilities in any manner or form.

I have read and agree to the privacy notice

Type your full name as your signature (patient or guardian) Date

If paying by check, you must provide 2 forms of ID and your Social Security number at your visit.

Thank you. Your form has been submitted.

The server accepted your submission for email delivery to the clinic.

If you need urgent medical help, call 911 or visit the nearest emergency department.