First Name                                         Last Name                                   Middle Initial                               

Phone                                                    Cell                                                  DOB                                         

Sex               Marital Status               Address:                                                                                           

City                                                         State                    Zip                                                                      

Employer                                 Employer’s Phone                              Is employment for patient?             

If patient is a minor: In case of Emergency please notify: Father Name                            
Mother Name                                                          Phone                                                                


INSURANCE INFORMATION

Primary Insurance:                               ID#                                        Group/Policy#                                          

Insured Name:                                      Insured DOB                       Relationship to Patient                           

Insured Address                                                                                                                 


Secondary Insurance:                          ID#                                    Group/Policy#                                           

Insured Name:                                        Insured DOB                         Relationship to Patient                    

Insured Address (if different from above)                                                                                                              


Primary Doctor’s Name:                                                Phone:                                                          
Referred by:                                                                      Phone                                                            
Pharmacy Name:                                                             Phone                                                            


CO-PAYMENTS ARE DUE UPON ARRIVAL*


AUTHORIZATION
I authorize Dr. Maher N. Nashed to treat the above named patient.
I authorize the use of this form for all of my insurance submissions;
It is my responsibility to immediately notify the staff of any insurance changes.
I authorize the release of information to all my insurance companies.
I authorize my doctors to act as my agent in helping me obtain payments from my insurance companies.
I authorize direct payment to Dr. Maher N. Nashed.
I understand that I am responsible to obtain referrals from my PCP. 
If no referrals are provided, I understand that I am responsible for payment for services
rendered by Dr. Maher N. Nashed.
I understand that I am responsible for payments for services rendered by Dr. Maher N. Nashed.
I permit a copy of this authorization to be used in place of the original.
By putting your name in the box below, you agree with all the above terms as if you are signing in person.

PATIENT’S NAME: -------------------------------------- Signature: -----------------------------Date:  ---------         


PATIENT UNDER 18- LEGAL GUARDIAN Name:------------------------------------

Signature:--------------------------------------------    Date:----------------------------------                



New Patient Forms
       Welcome to our office

Please, click on the pins in the boxes below to open the new patient forms in your computer. They are in MW (Microsoft Word) or PDF. Fill them and bring them with you. If you cannot open these links, you can print the forms below, fill in the spaces and bring them with you.

The initial visit will be only for consultation. If allergy skin testing is needed, testing will be schedule on another visit.

Remember:
1. No Antihistamines or antidepressents (Consult your physician before stopping the medicines) for 72 hours before the allergy testing visit.
2. Bring your insurance card and your referral (if needed)

If unable to keep any appointment, kindly give 24 hours notice.

Thank you for your cooperation.
  • Nasheds PA                                                 New Patient Information
  • Present occupation(describe):_____________________________Duration:____________________________
  • Past occupation(describe):___________________________________Duration:_________________________
  • Main problems now: _________________________________________________________________________
  • ___________________________________________________________________________________________
  • Please give us more details about your problems


Breathing Problems/Asthma:
How long do you have it?_________ Is it year round or seasonal?________________________
Most recent episode:_________ How long it did last?________ Treatment used:____________
Things bring it on/make it worse:______________________ Things make it better:__________
Is it the same, worse, or better since started? ________
How often you get them per week or month? _______ How many of them are at night? _____
is it worse by day or by night? __________ How long the symptoms last? ________________
What do you feel? _______________________________________________________________
Do you get wheezing when you get the air in or out? __________________________________
How many ER visits or hospitalizations you had? ____________________________________
Your breathing medications: ______________________________________________________
How often you use? The rescue medication per week: ________________________________
the other medications per week: __________________________________________________

Sinus Infections:
How long do you have them? __________ How many infections per year? _______________
How long each last? _________ What was the treatment? _____________________________
Did you have a sinus CAT scan? ________ Did you had sinus surgery? _________________
How many? ______ When was the last one? __________
What are your symptoms when you have a sinus infection? ___________________________

Nasal Congestion/Stuffy Nose:
How long do you have it? _______ Is it year round or seasonal? ________________________
Is it daily or on/off? _______ How long it last when you have it? _________
Is it one side or both? __________ Things make it worse __________________________
Things make it better: ___________________________
is it the same, worse, or better since started? _________
What are your allergy medications: _________________________________________________

Sneezing:
How long do you have it? _______ Is it year round or seasonal? _________
How long it last? ______ Things bring it on: _____________________________
Is it the same, worse, or better since started? ________

Cough:
How long do you have it? ______Is it year round or seasonal? ______
How often do you cough? _____ Things make it worse: _______________________________
Things make it better: ____________________ Is it dry or wet? _______
Is it worse by day or by night? ______Is it the same, worse, or better since started? _______
Do you cough with activities? ______ Your cough medications: ________________________
_______

Itchy and Watery eyes:
How long do you have it? ____________ Is it year round or seasonal? _____________
How long it last? ________ Is it one side or both? ____________
Things make it worse: ___________________ Things make it better: ____________________
Is it the same, worse, or better since started? _____
Your Eye medications: __________________________________________________________

Hives and Rash:
How long do you have it? ______ Is it hives or rash? ______ Is it year round or seasonal? __
How many times you had it? _______ How long it last? ______________
Where hives/rash started? ________ Where did it go from there? ______________________
Things make it worse:_________________________Things make it better:________________
Do you have any pictures?__________ What it looks like? _____________________________
Is it the same, worse, or better since started? ______
Your rash or itching medications: __________________________________________________

Post Nasal Drip or Clearing the throat:
How long do you have it?_________ Is it year round or seasonal?_____ 
How long it last when you have it? Minutes______ Hours_____ Days_______ Months_____
All the time_____ Things make it worse:___________________ Things make it better:______
Is it the same, worse, or better since started?____________
Is it worse by day time or by night?____________ Does exercise affect it:________
Medications used for it:____________________________________________

Heart Burn:
How long do you have it? ______ Is it year round or seasonal?______
How often you get it?_____ How long it last?__________ Where do you feel it?__________
Things make it better:______________Things make it worse:__________________________
Is it the same, worse, or better since started?_________
What other symptoms do you feel with it?_____________________
When is the worse time?______________

Snoring:
How long do you have it?______ Do you have it every night?_________
Is it worse on one side?_____ Things make it worse :________________________
Is it the same, worse, or better since started:__________
Witnessed stop breathing at night?_______ Witnesses stop breathing duration:__________
How to you feel in the morning?_______________________________________________________________

Nose bleeds:
How long do you have it? _____ Is it year round or seasonal? ________
How long it last?_______ One side or both?_________________
Things make it worse:________________________________________
Things make it better:__________________________ Is it the same, worse, or better since started?_________
Have you had any trauma to your nose?____________ Do you have bleeding problem?___________________

Frequent Infections:
How many colds/bronchitis/sinusitis/ear infections/other infections you get per year? ____________________
How many years do you have them?_______ How long each last? _______
How many pneumonia you had in your life time? ________
How these infections were treated? _______________________________________
Please, bring with you any blood work results you have. 

Headache:
How long do you have it?______ Is it year round or seasonal?__________
How many times per week/month? ____________ How long it last?____________ 
Where is the headache?___________________ Things make it worse:____________________
Things make it better:______________________
Is it the same, worse, or better since started?________
Have you had any trauma to your head?____________  Did you have CT of the head? ______
Your headache medications:__________________________________

Ear Infections/Ear pain:
How long do you have it? ____ Is it year round or seasonal:____________
How many times per year?_____________ How long each last?_________
Is it the same, worse, or better since started? __________
Other symptoms you feel with it: __________________________________________________

Bee Sting Allergy:
When did it start?__________________ How many stings you had at the first time?_______
Where was the sting? __________what were the symptoms? __________________________
What was the treatment?__________________________________________________________
Do you have an Epipen?_______ Have you been stung after the first one ?_____
If yes, How many times?_____ Describe the reactions and their treatments: _____________
________________________________________________________________________________

Drug Allergy:
Please list medications names, when you had the reaction and what was the reaction.  
Please use one line for each medication, thanks. _____________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

What are other diseases you might have/had? _________________________________________
What are other things you are allergic to not mention above like food, chemicals
or other drugs?
Please, write each on a separate line, when it happened and the reaction to it. ____________
________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

What are the health conditions that run in your family? Check beside the one applicable
to you: Allergy_____ Asthma_______ Cancer_______ Diabetes _____High Blood pressure___
Others__________________

Home Environment:
How old is your home?______ Is it?  Rural _________suburban ________ city_________
Is your House? Single family____ Apartment _____ Mobile _____ Townhouse _____
Others:_______________
Do you have: Public water _____Well water_____ Natural gas for heating or cooking_______
Central air/heat________ Window air condition_______ Electric heat_____ Fire place_______
Cats _____Dogs______
Please, write other animals inside or outside the house and their number if possible ______
_________________________________ Carpet in the bedrooms: ________Living room:_____
Are you renovating/repairing your home?_________
Any smoking inside or outside the house:_____________

Smoking:
if you do you or did smoke, how many years in your life time did you smoke? _______
What is the average packs per day during these years?___________________________

Please list all other Medications, including vitamins, you take but did not mention above.
Please write the names, dose and for how long you have been taking them.
You can also bring the list of medications on a paper if they are many.
You can write any other concerns you might have, Thanks. ____________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________



Questions Form
  • PATIENT INFORMATION Form