Anita Carmen Choy, MD

Welcome to the new online home of Allergist Anita Carmen Choy, MD. Currently serving adults and children suffering from allergies and asthma, Dr. Choy is a Board Certified Allergist, providing comprehensive medical care for adult and children in the Silicon Valley since 1995.

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Patient History Form 2024

Welch Pasteur Allergy Medical Group, Inc

Anita Carmen Choy, MD. |. Hailen Mak, MD
211 Quarry Road, Suite 106 MC 5996,
Palo Alto, CA 94304
Ph: 650.322.3847  |  Fax: 650.322.3249

Patient History / Health Screen

If you have nose or allergy problems, please check all the following that make your symptoms worse:

Seasonal
Perennial
Non-Allergic
Are you allergic to any medications?
Please specify your reaction to any drugs you list
Are you taking any medications currently?

Please list your current medications:

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Do you currently have any of the following? (Please check all that apply)

Respiratory
Skin
Gastro-Intestinal
Psychiatry
Miscellaneous

Have you had any of the following in the past? (Please check all that apply)

Respiratory
Skin
Gastro-Intestinal
Psychiatry
Miscellaneous

Your Past Surgical History

Have you had any surgeries in the past? (please check all that apply)

Your Family's Medical History

Please select any conditions your immediate family may have suffered from in the past
Are you an only child or so you have sibling(s)?
Father
Mother
Brother
Sister
Grandfather
Grandmother

Your Smoking History

Are you exposed to any secondhand smoke?
What kind of exposure ?
Do you currently smoke?
Have you smoked in the past?
Any illicit drug use in the past?
Any current illicit drug use?
Do you use a vape pen?
What type of vape pen?

Your Drinking History

Do you drink alcohol?

Home Questionnaire (for allergies)

What type of flooring in your bedroom?
What type of windows?
Mattress Type
Pillow Type
Do you have dust mite covers?
Select all covers you use:
Do you have any pets?
What kind go heating do you have?
What type of vacuum do you use?
Do you keep books in the bedroom?
Do you have upholstered furniture in the bedroom?
Where do you live?
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