Health History Form


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119 East Bell Street Neenah, WI 54956 Ph: (920) 969-1768 Fx: ( 920) 267-5222

Health History Form Please answer ALL questions Patient Name: ________________________________

Date: ________________________

Reason for today’s visit: ___________________________________________________________________________ Date of Birth: ___________________Age: ______

Referring Provider: __________________________

Symptoms (Check all that apply) Ears, Nose

Congestion Runny nose Sneezing Sore throat Other:

Eyes

Redness Drainage

Chest

Cough Chest tight Other: Worse with: Hot/humid air Other: Better with: Other complaints:

Medications: 1. 2. 3. 4. 5.

and Throat

Throat drainage Itchy nose Mouth breathing Nosebleeds

Face pain Teeth pain Snoring Ear pain

Loss of taste Loss of smell Hoarseness Ear congestion

Ear infections Sinus infections Headaches Hearing loss

Itching Swelling

Burning Other:

Watering

Vision changes

Shortness of breath Difficulty breathing

Wheeze Chest Pain

Throat tightness Chest congestion

Dizziness Stridor

Night time Exertion

Day time Strong smells

Outdoors Anxiety

Cold/dry air “Colds”/infections

Inhalers

Cough Syrup

Rest

Lying down

6. 7. 8. 9. 10.

Medication Allergies Name of Medication

Medical History

Asthma Seasonal Allergies Food Allergy Eczema Hives Surgeries:

Family History

Thyroid Disease Psoriasis Stomach/Acid Reflux High Blood Pressure Diabetes

Type of Reaction

Emphysema Sleep Apnea Kidney Disease Depression Anxiety Date:

Other:

Condition: Affected Family Members Condition: Affected Family Members Asthma Cystic Fibrosis Seasonal Allergies Emphysema/COPD Food Allergies Thyroid Disease Hives Diabetes Eczema Other: Environmental History I live in a: [ ] House [ ] Apartment [ ] Duplex [ ] Mobile Home/Trailer Age of Home: ________________ How long have you lived there? _______________ Type of Heat: [ ] Forced Air [ ] Wood burning [ ] Hot water [ ] Electric [ ] Pellet stove Air conditioning: [ ] Central [ ] Window/Wall [ ] None Air Cleaner Type: _______Humidifier/Dehumidifier?________ % of home carpeted: _____ Patient’s room carpeted? _____ Known mold or mildew? __________________________ What pets do you have in the home? _______________________________ Are they in the patient’s bedroom? _______ Does anyone smoke at home? Y/N Who? Patient is a: [ ] Smoker : ____packs/day [ ] Non-smoker [ ] Quit smoking in: __________ Smokeless Tobacco?_______ Mark any that all that apply (over the last 4-6 weeks) Review of Systems General Ear, Nose and Throat Eyes Respiratory o Weight gain/loss o Nasal polyps o Vision changes o Bronchitis o Fever/chills o Hearing problems o Glaucoma o Pneumonia o Night sweats o Ringing in ears o Eye pain o Productive cough o Poor appetite o Voice changes o Eye discharge o Coughing up blood o Weakness o Recurrent Strep o Circles under eyes o Pain with breathing Skin: Cardiology Gastro-intestinal Musculoskeletal o Rash o Chest pain o Heartburn o Joint stiffness o Sensitive skin o Palpitations o Vomiting o Joint swelling o Easy bruising o Leg swelling o Diarrhea o Joint pain o Swelling o Fainting o Bloody stools o Muscle pain o Reaction to latex o o Stomach pain o Jaw pain Neurology Blood/Lymph Endocrine Kidney o Headache o Swollen glands o Excessive sweating o Kidney stones o Migraine o Fatigue o Excessive thirst o Excessive urination o Seizures o Clotting problems o Heat intolerance o Decreased urination o Memory loss o Anemia o Cold intolerance o Incontinence