Patient Name:________________________ Date of Birth:________________________ Today’s Date:________________________
Patient History
Who is the patient’s primary Doctor (first and last name) _____ _________________________________ Who referred the patient to our practice?___________________________________________________ Name and location of preferred pharmacy:__________________________________________________ What are your concerns for today’s visit? ___________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Review of Symptoms: Please circle to indicate whether the patient currently has any of the following symptoms:
ALLERGY
Sneezing
ENT
Ear pain/itch Dizziness
Post-nasal drip Ear drainage Throat clearing
Hearing loss Nasal congestion
Sense of smell
Problem snoring/apnea
RESPIR
Cough
Shortness of breath
EYES
Eye pain
Watery or itchy eyes
GI
Difficulty swallowing
Heart Burn
NEURO
Headache
Passing out
GENERAL
Fever/chills
Weight loss/gain
ENDO
Warmer than others
Cooler than others
HEME/LYM
Swollen glands
Night sweats
CARDIAC
Chest pain
Palpitations
SKIN
Rash/hives
Skin or hair changes
PSYCH
Depression/anxiety
Mental health problems
Noises in ear Sinus pressure/pain
Hoarseness
Fatigue
Throat pain
Daytime sleepiness
Bleeding problems
Easy bruising
Past Medical History: Please check the “Yes” or “No” box to indicate whether the patient has any of the following illnesses. For the “Yes” answers please explain. Yes
No
Diabetes
( )
( )
_________________________________________
Hypertension (high BP)
( )
( )
_________________________________________
Thyroid Problems
( )
( )
_________________________________________
Heart Disease/cholesterol
( )
( )
_________________________________________
Respiratory Problems
( )
( )
_________________________________________
Stomach/Intestinal Problems
( )
( )
_________________________________________
Allergy Problems/Therapy
( )
( )
_________________________________________
Cancer
( )
( )
_________________________________________
Neurological Problems
( )
( )
_________________________________________
Bleeding disorders
( )
( )
_________________________________________
Reaction to Anesthesia
( )
( )
_________________________________________
Recurrent Infections
( )
( )
_________________________________________
Other Medical Diagnosis
( )
( )
_________________________________________
Any Chance of Pregnancy?
( )
( )
_________________________________________
List any operations (month/year) the patient has had: _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________
List any medications the patient is allergic to or has had a reaction to: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
List any medications the patient is currently taking including dose/number of times per day: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Social History: Yes
No
Details
( )
( )
_____________________________
( )
( )
_____________________________
Drink Alcohol? List frequency/amount
( )
( )
_____________________________
Illicit drug use, current or past?
( )
( )
_____________________________
HIV risk factors?
( )
( )
_____________________________
Smoke/chew tobacco? How Much? If no, did patient smoke previously?
What is the patient’s occupation? ________________________________________________________
Family History: Please indicate if any blood relatives (parents, siblings, grandparents, aunts, uncles, cousins) of the patient have had any of the following illnesses. If yes please indicate which relative(s):
Yes
No
Details
Hearing problems
( )
( )
_____________________________
Allergies
( )
( )
_____________________________
Cancer
( )
( )
_____________________________
Bleeding/clotting disorder
( )
( )
_____________________________
Anesthesia problems
( )
( )
_____________________________
Your signature: __________________________________________
Sinus/Allergy Questionnaire 1. How long have you had sinus problems? ______________________________________________________________________________ ______________________________________________________________________________ 2. What antibiotics have you been on and for how many days? ______________________________________________________________________________ ______________________________________________________________________________ a. How many infections do you get per year?_____________________________________ b. What antihistamines and nasal sprays have you tried? Did they help? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ c. Have you been given Prednisone or steroids before? _______When?________________ 3. When did you complete your most recent antibiotic?___________________________________ 4. What treatment seemed to relieve your symptoms the best?_____________________________ 5. What are your sinus problems?_____________________________________________________ ______________________________________________________________________________ 6. Do you have hard time breathing out of your nose? Is one side worse than the other? ______________________________________________________________________________ _____________________________________________________________________________ 7. What one symptom bothers you the most?___________________________________________ 8. What season bothers you most?____________________________________________________ 9. What pets do you have?___________________________________________________________ a. How long have you had them?_______________________________________________ 10. Have you ever had any head or neck surgery?_________________________________________ a. When?__________________________________________________________________ 11. How is your sense of smell?________________________________________________________ 12. Have you been allergy tested in the past?_____________________________________________ 13. What allergy treatment have you had in the past (include medications and shot history)?_______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Patient signature:___________________________________________
Date:______________
Physician signature:___________________________________________Date:_______________
Ear Questionnaire 1. What symptoms are you or your child having? ________________________________________________________________________ ________________________________________________________________________ 2. How many ear infections do you or your child get per year? ________________________________________________________________________ 3. What antibiotics have been tried and for how long were they taken? ________________________________________________________________________ ________________________________________________________________________ 4. Which antibiotic works best?________________________________________________ 5. Have you or your child taken preventative antibiotics?____________________________ a. Did it work?_______________________________________________________ 6. What one symptom bothers you the most?____________________________________ 7. Do you think there is a hearing loss?_____________Which ear is better?_____________ 8. Are there any balance difficulties?____________________________________________ 9. Do you have any ringing/noises in your ears? ____________ Which ear?_____________ a. Does the noise sound like a heartbeat?_________________________________ 10. Has there been any previous ear surgery? ______________ Which ear?_____________ 11. Has there been any noise exposure (firearms, power tools, military)?________________ 12. Is there any family history of hearing loss?_____________________________________ 13. Have you had any dental work done recently or are you in need of any? ________________________________________________________________________ ________________________________________________________________________ 14. Does your ear have drainage or fluid leaking out of the canal?______________________ 15. Do you experience any feeling of fullness, pressure, or ear pain?____________________
Patient Signature_________________________________________ Date________________ Physician signature_______________________________________ Date________________
Dizziness Questionnaire Please answer all questions: 1. When you are “dizzy”, do you experience any of the following sensations? Lightheadedness Swimming sensation Blacking out Loss of consciousness
Yes Yes Yes Yes
No No No No
Tendency to fall: To the right? To the left? Forward? Backward?
Yes Yes Yes Yes
No No No No
Objects spinning around you? Sensation that you are turning or spinning inside While outside objects remain stationary?
Yes Yes Yes
No No No
Loss of balance when walking: Veering to the right? Veering to the left?
Yes Yes
No No
Headaches Yes No Nausea Yes No Vomiting Yes No Pressure in the head Yes No Other - Explain: ____________________________________________________________________ ____________________________________________________________________
2. Mark “Yes/No” and answer the questions in the space provided. When did your dizziness first occur?_______________________________________ Is your dizziness intermittent or constant?__________________________________ Does your dizziness occur in attacks? If yes, how often? _______________ Length of episode?_______________
Yes
No
Can you tell when an attack is about to start?
Yes
No
If yes, how?________________________________________________________ Are you completely free of dizziness between attacks?
Yes
No
Does change of position make you dizzy?
Yes
No
Do you have trouble walking in the dark?
Yes
No
When dizzy, can you stand up unsupported?
Yes
No
Do you know any possible causes on the dizziness?
Yes
No
Stop your dizziness?
Yes
No
Make your dizziness better?
Yes
No
Do you know anything that will:
If so what?________________________________________________________ Bring on an attack?
Yes
No
If yes, what?_____________________________________________________ Is there a relationship between eating and your dizziness?
Yes
No
Were you exposed to any irritating fumes, paints, etc?
Yes
No
If yes, what?________________________ _____________________________ Do you have allergies?
Yes
No
Did you ever injure your head?
Yes
No
If yes, please describe:____________________________________ __________ Do you take medications regularly?
Yes
No
If yes, please list:__________________________________________ _________ Do you use tobacco in any form?
Yes
No
If yes, how much:___________________________________________________ Do you feel that you are under undue stress?
Yes
No
Do you drink alcohol?
Yes
No
If yes, how much:______________ ____________________________________
Has anyone in your family had similar dizziness?
Yes
No
If yes, who:________________________________ _______________________ 3. Do you have any of the following symptoms associated with ears? Difficultly hearing? Noise in your ear? Fullness, stuffiness, or pressure? Pain in ears? Discharge from ear?
Right ear Right ear Right ear Right ear Right ear
Left Ear Left Ear Left Ear Left Ear Left Ear
Do any of these symptoms change with dizziness?
Both Both Both Both Both Yes
None None None None None No
If yes please describe:_______________________________________________ Have you been exposed to a loud noise?
Yes
No
If yes , when and for how long?________________________________________ Has anyone in your family had hearing problems?
Yes
No
If yes, please explain:________________________________________________
4. Have you ever experienced any of the following symptoms? Double vision Blurred vision Blindness Numbness of face Numbness of arms or legs Weakness of arms or legs Clumsiness of arm or legs Mental confusion Loss of consciousness Difficulty swallowing
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No No No
Constant Constant Constant Constant Constant Constant Constant Constant Constant Constant
Episodic Episodic Episodic Episodic Episodic Episodic Episodic Episodic Episodic Episodic
Thank you for taking the time to fill out this form. Please be sure that you have answered all questions. This will assist in the final report and assessment of results.
Patient Information
Date________________ Referring M.D.______________
Last Name____________________________________ First Name______________________ MI______ Address:_______________________________ City_______________________State:_____ Zip________ Home Phone:___________________________ Work Phone:____________________________________ Patient’s Birthdate:___________________ Age:________ SS#__________________________________ Patient is:
___M-Male
___F-Female
___MN-Minor
___S-Single
___M- Married ___D- Divorced
___W-Widowed
Responsible Party/Insurance Holders information Responsible for account? Last name:
____________
First
_______ _______
Relationship to patient: ____________________ Do you have Insurance?
Yes
No
If yes, we will need a copy of your insurance card(s) Medicare #: __________________________________ Medicaid #: __________________________________ Guarantor and/or Insurance Holder: Last Name:________________________ First Name:________________________ Address:_______________________________ City_______________________State:_____ Zip________ Home Phone:___________________________ Work Phone:____________________________________ Cell Phone:______________________________ Emergency Phone:______________________________ Insurance Holder’s Birthdate:___________________ Insurance Holder’s SS#_______________________
Insurance Co.:______________________________Group #______________Member #______________ Address:_______________________________ City_______________________State:_____ Zip________ Employer:_____________________________________________________________________________
Secondary Insurance: Yes
No
Insurance Holder______________________________________
Insurance Holder’s Birthdate:___________________ Insurance Holder’s SS#_______________________ Insurance Co.:______________________________Group #______________Member #______________ Employer:___________________________Second insurance billed on surgeries and allergy testing only. Copy of card required. Race: ____ A-Asian
____D-Subcontinent Asian American ____G-Native American
____B-Black/African American ____E-Other Race
____P-Pacific Islander
____C-Caucasian
____ M –More than one race
____F-Asian Pacific American
Ethnicity: _____ L-Latino Hispanic
_____O-Other
_____Not reported/refused
Additional Note: If the physician determines an office procedure is required (including endoscopy) your insurance carrier may process this as a surgical procedure. Depending on your insurance policy, this could be processed under different benefit guidelines resulting in a surgical deductible.
____________________________________
_________________________________
Patient/Guarantor Signature
Date
Referral source to our practice: [ ] Ref MD
[ ]Insurance
[ ]Ref SVC
[ ]Phone book
[ ]Friend/Relative
[ ]Internet
[ ] Employee
[ ]Walk-In
[ ]Other:______________
