Patient History Details
First Name
Last Name
Email ID
MI
Age
Gender
Male
Female
DOB
WHO REFERRED YOU TO US?
HAS ANYONE IN YOUR FAMILY BEEN SEEN HERE BEFORE?
Yes
NO
IF SO, WHO & WHY?
REASON FOR TODAY'S VISIT:
PRIOR SURGERIES:
DRUG ALLERGIES:
MEDICAL ILLNESSES:
PLEASE LIST CURRENT MEDICATIONS:
BLEEDING OR ANESTHESIA PROBLEMS?
Yes
NO
IF YES, PLEASE EXPLAIN:
DO YOU SMOKE?
Yes
NO
AMOUNT:
DID YOU EVER SMOKE?
Yes
NO
AMOUNT:
DO YOU DRINK ALCOHOL?
Yes
NO
AMOUNT:
DID YOU EVER DRINK ALCOHOL?
Yes
NO
AMOUNT:
FAMILY HISTORY OF:
CANCER
BLEEDING DISORDER
HEARING LOSS
DIABETES
PREGNANT?
Yes
NO
WEEKS GESTATION:
TIME IN NICU_:
WAS CHILD EVER ON A VENTILATOR?:
ARE YOU CURRENTLY EXPERIENCING: (CHECK ALL THAT APPLY)
EAR:
HEARING LOSS
Yes
NO
VERTIGO OR DIZZINESS
Yes
NO
UNSTEADINESS
Yes
NO
HEAD NOISE OR TINNITUS
Yes
NO
EAR PAIN
Yes
NO
EAR DRAINAGE
Yes
NO
EAR PRESSURE
Yes
NO
NOISE EXPOSURE
Yes
NO
WEAR HEARING AID(S)
Yes
NO
NOSE:
BLEEDING
Yes
NO
RUNNY NOSE
Yes
NO
SNEEZING
Yes
NO
ITCHY NOSE
Yes
NO
POST NASAL DRIP
Yes
NO
HEADACHES
Yes
NO
FACIAL PRESSURE
Yes
NO
NASAL OBSTRUCTION
Yes
NO
THROAT:
SWALLOWING DIFFICULTY
Yes
NO
THROAT PAIN
Yes
NO
REGURGITATION
Yes
NO
HOARSENESS
Yes
NO
COUGH
Yes
NO
COUGHING BLOOD
Yes
NO
SWOLLEN NECK GLANDS
Yes
NO
SNORING
Yes
NO
BREATHING CESSATION DURING SLEEP
Yes
NO
GENERAL:(if Yes,Please explain below)
HEART TROUBLE
Yes
NO
CHEST PAIN/ANGINA PECTORIS
Yes
NO
SHORTNESS OF BREATH
Yes
NO
ABDOMINAL PAIN OR HEARTBURN
Yes
NO
NAUSEA OR VOMITING
Yes
NO
STROKE
Yes
NO
HEAD INJURY
Yes
NO
THYROID DISEASE
Yes
NO
HIGH OR LOW
Yes
NO
PAST TRANSFUSION
Yes
NO
BLEEDING OR BRUISING TENDENCY
Yes
NO
ARTHRITIS
Yes
NO
DIABETES
Yes
NO
RISK FACTORS FOR HIV/AIDS
Yes
NO
FATIGUE
Yes
NO
WEIGHT LOSS
Yes
NO
PSYCHIATRIC ISSUES
Yes
NO
LIVER PROBLEMS/DISEASE
Yes
NO
ALLERGY/IMMUNE DISORDERS
Yes
NO
BLOOD DISORDERS
Yes
NO
NEUROLOGICAL PROBLEMS
Yes
NO
HISTORY OF CANCER
Yes
NO
EXPLAIN ANY YES ANSWERS:
SIGNATURE:
DATE:
NAME OF PERSON FILLING OUT FORM:
RELATIONSHIP TO PATIENT:
(FOR PHYSICIAN/OFFICE USE ONLY)-(NOT TO BE FILLED OUT BY PATIENT):
LOCATION:
____________
QUALITY:
____________
SEVERITY:
____________
TIMING:
____________
DURATION:
____________
CONTEXT:
____________
MODIFYING FACTORS:
________________________
ASSOCIATED SIGNS & SYMPTOMS:
________________________
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