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PATIENT INFORMATION Patient Name________________________________________________ Last Name
First Name
Birth Date_________________________
Middle (initial)
Patient Employer___________________________________________ Patient Occupation ________________________
Reason For Your Visit Today_________________________________________________________________ Doctor who referred you ___________________ Who is your regular doctor? _________________________ PAST OR PRESENT MEDICAL PROBLEMS (Circle any problems you have or had): High Blood Pressure Diabetes Allergies Rheumatic Fever HIV/AIDS Depression Jaundice Angina Asthma Ear Infections Kidney Stones Hepatitis (A B C) Fibromyalgia Head Injury Heart Attack Bronchitis Hearing Loss Kidney Failure Arthritis Chicken Pox Goiter Irregular Heart Rate Emphysema Meniere’s Disease Urinary Infection Anemia Blood Clots TMJ Other Heart Disease Tuberculosis Sinus Infections Seizures Stomach Ulcers Excessive bleeding Pneumonia Bleeding Disorder Cancer (Type/when):_________________ Stroke Tonsillitis Women: Are you Pregnant …… No Yes Please list all other Illnesses: _______________________________________________________________________________________________________
____________________________________________________________________________________________________ _____________________________________________________________________________________________________ SURGICAL HISTORY (Please circle any surgeries you have had, and when) Ear Tubes Tonsillectomy Thyroid Surgery Knee Replacement Hysterectomy Gall Bladder Prostate Surgery ______________________
Ear Drum Repair Septum Repair Cardiac Bypass Hip Replacement Tubal Ligation Appendectomy Hernia Mastoidectomy Sinus Surgery Cataracts Cesarean Section Skin Cancer Please List Other Operations (please list type): _________________________________________________________________________________________
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ List All Current Medications
Are You Allergic To? (including over-the-counter) (Please Circle No or Yes) ______________________ Penicillin….….… No Yes ______________________ Sulfa…………….. No Yes ______________________ “Mycin” …..…….. No Yes ______________________ Aspirin…………... No Yes Codeine…………. No Yes ______________________ Tetanus………….. No Yes ______________________ Demerol……….… No Yes ______________________ Other Medications. No Yes ______________________ List Other Medication ______________________ Allergies: ______________________ ___________________ ______________________ ___________________ ______________________ ___________________ ______________________ _______________ ______________________ ___________________ ______________________ EARS/NOSE/MOUTH/ THROAT ___________________ ______________________ Hearing loss none right___________________ left both ______________________ Ringing in ears none right___________________ left both ______________________ Ear pain none right left both ___________________ Ear Drainage none right left both Previous ear surgery: none right___________________ left both ___________ Chronic sinus probs no Nasal obstruction no Nosebleeds no Mouth sores no Chronic sore tongue no Sore throat no Voice change no Hoarseness no Difficulty swallowing no Painful swallowing no Swelling in neck no
yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________
FAMILY HISTORY
SOCIAL HISTORY
Anyone else in the family with the same problems?
Number of Children__________________ Do you use Tobacco? ……….… No Yes Packs per day_____Years ______ Stopped Tobacco When?___________ Alcohol Usage ………..………. No Yes Type/Quantity _________________ Do you use Street Drugs …....…. No Yes Ever had a blood transfusion? .… No Yes
_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________
FOR CHILDREN less than 12 years old: Birth Weight______________________ Prenatal problems?_______________ Immunizations up to date?___________ Number of people in home___________ Any second hand smoke?____________ Any house pets?___________________ Grade Level______Day Care?________
GENERAL Good General health Easy Bleeding Easy Bruising Heart trouble Chronic cough Heartburn Frequent Headaches Thyroid disease Double vision
no no no no no no no no no
yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________ yes____________________
no no no no no
yes____________________ yes____________________ yes____________________ yes____________________ yes____________________
ALLERGIC Hay fever Food allergies Eye itchiness Nose itchiness Sneezing