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Freehold Township, NJ
Hillsborough Township, NJ
Lawrenceville, NJ
Monroe Township, NJ
Mount Laurel Township, NJ
Mullica Hill, NJ
Philadelphia, PA (South St)
Philadelphia, PA (Walnut St)
Plainsboro, NJ
Princeton, NJ (Bunn Drive)
Princeton, NJ (Ewing Street)
Robbinsville Township, NJ
Sewell, NJ
Voorhees Township, NJ (East Evesham Rd)
Voorhees Township, NJ (Haddonfield-Berlin Rd)
Voorhees Township, NJ (Sheppard Rd)
Woodbury, NJ
Yardley, PA
Our Services
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Nose & Sinus
Urgent Care
Balloon Sinuplasty
Deviated Septum
Loss of Smell and Taste
Nasal Congestion and Blockage
Nasal Polyps
Nosebleeds
Post-Nasal Drip Treatment
Sinusitis
Sinus Pressure and Pain
Sinus Headaches
VivAer® and RhinAer® Treatments
Urgent Care for Sinus Infection
Ears
Comprehensive Ear Wax Buildup Care
Ear Infections
Eustachian Tube Dysfunction
Hearing Aids
Hearing Loss Treatment
Tinnitus Treatment
Urgent Care for Ear Infection
Head and Neck
Airway Problems
Dizziness & Vertigo Treatment
GERD
Neck and Branchial Cleft Cysts
Neck Masses
Salivary Gland Masses
Thyroid Disease
Sleep & Snoring
Central Disorders of Hypersomnolence
Circadian Rhythm Sleep-Wake Disorders
Insomnia Disorders
Oral Appliances
Parasomnias
Sleep Apnea Treatment
Sleep-Related Breathing Disorders
Sleep-Related Movement Disorders
Snoring & Sleep Treatment
Turbinate Reduction
Throat
Swallowing Disorders Treatment
Voice Disorders
Gender-Affirming Voice Therapy
Tonsil Infections
Professional Voice Disorder
Stroboscopy
Voice Therapy
FEES
Chronic Cough
Laryngitis Treatment
Laryngopharyngeal Reflux
Pediatric
Pediatric ENT
Adenoid Hypertrophy
Tonsil and Adenoid Surgery
Allergy
Allergic Asthma
Allergic Conjunctivitis
Allergic Contact Dermatitis
Allergic Rhinitis
Anaphylaxis
Angioedema
Drug Allergy
Food Allergy
Latex Allergies
Mold Allergies
Penicillin Allergy
Pet Allergy
Pollen Allergy
Seasonal Allergies
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Initial Visit Questionnaire Allergy-Immunology
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Patient Name
*
Email
*
Date of Birth
*
Who referred you for your allergy evaluation?
*
What is the primary reason for your referral?
*
Have you ever been diagnosed with allergic rhinitis (seasonal allergies)?
*
Yes
No
If Yes, have you ever had skin or blood testing before?
*
Yes
No
Have you ever been on allergy shots before?
*
Yes
No
What triggers your symptoms? (check all that apply)
*
Pollens
Grass
Dust
Wind
Fumes
Smoke
Perfume
Cats
Dogs
Vacuuming
Mowing
Exercising
Temperature Changes
Illness
Cold Weather
Other Animals
Other
Other Animals
*
Other
*
Have you ever been diagnosed with asthma?
*
Yes
No
Are you on any asthma medications?
*
Yes
No
If yes, what medications are you taking?
*
Have you ever been diagnosed with atopic dermatitis (eczema)?
*
Yes
No
Have you ever been diagnosed with chronic hives (urticaria) or angioedema?
*
Yes
No
Do you have a history of recurrent infections? (check all that apply)
*
Yes
No
Do you have a history of recurrent infections? (options)
*
Ear Infections
Pneumonia
Sinus Infections
Skin Infections
Bone Infections
Other
Other
*
Have you ever been treated with antibiotics (more than 2 weeks) for sinusitis?
*
Yes
No
Have you ever had an adverse reaction to foods?
*
Yes
No
Which food?
*
What happened?
*
Have you ever had an adverse reaction to a bee, wasp, hornet, or fire ant?
*
Yes
No
When?
*
What happened?
*
Are you allergic to any medications?
*
Yes
No
Medication
*
Reaction
*
Medication
Reaction
What type of home do you live in? (check one)
*
Single family home
Townhouse/Condo
Apartment
Barracks
Do you have the following in your home?
*
Carpet in bedroom
Carpet in Living Area
Drapes/Curtains
Visible mold/mildew
Window A/C unit
Central A/C Heat
Fire place
HEPA Filters
Humidifier
Do you have any pets (please indicate quantity) or other animal exposures
*
Yes
No
Cats
Dogs
Birds
Goats
Horses
Sheep
Cows
Other
Do you have any exposures at home, work, hobbies, etc. that concern you (chemicals, fumes, vapors, etc)?
*
Yes
No
Specify
*
In the last 3 months have you had any of the following signs or symptoms?
Fever
*
Yes
No
Nausea
*
Yes
No
Chills
*
Yes
No
Vomiting
*
Yes
No
Unexpected weight loss
*
Yes
No
Diarrhea
*
Yes
No
Cough
*
Yes
No
Skin Rash
*
Yes
No
Wheezing
*
Yes
No
Trouble with sense of smell
*
Yes
No
Shortness of Breath
*
Yes
No
Joint redness or swelling
*
Yes
No
Heartburn
*
Yes
No
Dizziness
*
Yes
No
Abdominal Pain
*
Yes
No
Headaches
*
Yes
No
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Call one of our locations now!
Freehold, NJ: (732) 375-9550
Hillsborough, NJ: (908) 271-2102
Lawrenceville, NJ: (609) 303-5163
Monroe, NJ: (609) 831-0779
Mt. Laurel, NJ: (856) 724-4031
Mullica Hill, NJ: (856) 478-3111
Philadelphia, PA: (215) 671-6330
Philadelphia, PA: (215) 929-8301
Plainsboro, NJ: (609) 681-6939
Princeton, NJ: (609) 759-8500
Princeton, NJ: (609) 430-9200
Robbinsville, NJ: (609) 436-5740
Sewell, NJ: (856) 589-6673
Voorhees, NJ: (856) 772-1617
Voorhees, NJ: (856) 565-2900
Yardley, PA: (267) 399-4004
Woodbury, NJ: (856) 845-8300
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Our Locations
Our Locations
View More Locations
Freehold Township, NJ
Hillsborough Township, NJ
Lawrenceville, NJ
Monroe Township, NJ
Mount Laurel Township, NJ
Mullica Hill, NJ
Philadelphia, PA (South St)
Philadelphia, PA (Walnut St)
Plainsboro, NJ
Princeton, NJ (Bunn Drive)
Princeton, NJ (Ewing Street)
Robbinsville Township, NJ
Sewell, NJ
Voorhees Township, NJ (East Evesham Rd)
Voorhees Township, NJ (Haddonfield-Berlin Rd)
Voorhees Township, NJ (Sheppard Rd)
Woodbury, NJ
Yardley, PA
Our Services
Our Services
Read Our Articles
Nose & Sinus
Urgent Care
Balloon Sinuplasty
Deviated Septum
Loss of Smell and Taste
Nasal Congestion and Blockage
Nasal Polyps
Nosebleeds
Post-Nasal Drip Treatment
Sinusitis
Sinus Pressure and Pain
Sinus Headaches
VivAer® and RhinAer® Treatments
Urgent Care for Sinus Infection
Ears
Comprehensive Ear Wax Buildup Care
Ear Infections
Eustachian Tube Dysfunction
Hearing Aids
Hearing Loss Treatment
Tinnitus Treatment
Urgent Care for Ear Infection
Sleep and Snoring
Central Disorders of Hypersomnolence
Circadian Rhythm Sleep-Wake Disorders
Insomnia Disorders
Oral Appliances
Parasomnias
Sleep Apnea Treatment
Sleep-Related Breathing Disorders
Sleep-Related Movement Disorders
Snoring & Sleep Treatment
Turbinate Reduction
Allergy
Allergic Asthma
Allergic Conjunctivitis
Allergic Contact Dermatitis
Allergic Rhinitis
Anaphylaxis
Angioedema
Drug Allergy
Food Allergy
Latex Allergies
Mold Allergies
Penicillin Allergy
Pet Allergy
Pollen Allergy
Seasonal Allergies
Throat
Swallowing Disorders Treatment
Voice Disorders
Gender-Affirming Voice Therapy
Tonsil Infections
Professional Voice Disorder
Stroboscopy
Voice Therapy
FEES
Chronic Cough
Laryngitis Treatment
Laryngopharyngeal Reflux
Head and Neck
Airway Problems
Dizziness & Vertigo Treatment
GERD
Neck and Branchial Cleft Cysts
Neck Masses
Salivary Gland Masses
Thyroid Disease
Pediatric
Pediatric ENT
Adenoid Hypertrophy
Tonsil and Adenoid Surgery
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