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Get NJ Hamilton Allergy Asthma And Sinus Center Patient Questionnaire

HAMILTON ALLERGY, ASTHMA AND SINUS CENTER, P.A. PATIENT QUESTIONNAIRE - Please fill as completely as possible Name Age Today's Date Rea son for visit: Please list current prescription and non-prescription medications (also list herbals, supplements, etc): *** When was the last time you took any antihistamine, cough/cold medicine or Singulair: PAST MEDICAL HISTORY - Check the box for either Yes , No or "Not sure" for each condition: Condition Yes No Unsure Condition Yes No Uns.

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