EAR, NOSE and THROAT, Ltd. Patient History Form Today s …

1 EAR, nose and throat , Ltd. Patient History form Today s Date: OVER Patient Name: DOB: ID#: B/P: P: R: T: // Wt: Ht: (To be done Today ) None ALLERGIES Medication Allergies Type of Reaction Other Allergies Type of Reaction None MEDICATIONS (Prescription, over-the-counter or herbal) Medication Dose How often Medication Dose How often 1. 6. 2. 7. 3. 8. 4 9. 5. 10. MEDICAL History : (Please check all that apply and CIRCLE the problem you are currently having, if available,) Ear / nose / throat : Yes Allergy Testing: (Ever had it done) Allergy Shots: Currently In the Past Allergy Shots - Relief ?: Ear: Drainage - Pain - Pressure - Wax Headache: Front - Top - Back / Sharp - Dull Hearing Loss: Right / Left / Both Nasal: Congestion - Drainage - Pain - Pressure Neck: Enlarged Nodes - Pain - Stiffness Sinus: Congestion - Drainage - Pain - Pressure throat : Clearing - Pain - Pressure Tinnitus: Rt / Lft / Both - Constant - Intermittent Salivary Gland: TMJ: Vertigo (Dizziness): Cardiovascular: Cardiovascular Disease: Elevated cholesterol (hyperlipidemia): High Blood Pressure (hypertension): Metabolic/endocrine: Diabetes: Type # I # II Thyroid deficiency (hypothyroidism): Thyroid excess (hyperthyroidism): Pulmonary: Asthma.

2 COPD/Emphysema: Sleep Apnea: Tuberculosis: Digestive: Yes Gastroesophageal Reflux / Heartburn: Hiatal Hernia: Neurologic: Migraine: Stroke: Musculoskeletal: Arthritis: Fibromyalgia: Fractures: Type Hematology: Anemia: Hepatitis: Type HIV / AIDS: Lupus: Mononucleosis: STD: Type Neoplastic: Cancer Type Genitourinary: Kidney Stones (Nephrolithiasis): Prostate enlargement (Prostatitis): Renal Failure (acute): Psychiatric: ADHD / ADD: Anxiety (adjustment disorder): Depression: Other: Glaucoma: EAR, nose and throat , Ltd. Patient History form Nurse s Initials:_____ ENT SPECIFIC SURGERY: Ear Tubes (BMTT) Where / When Ear Surgery (Internal) Where / When Ear Surgery (External) Where / When Nasal Surgery Where / When Sinus Surgery Where / When Tonsils and /or Adenoids Where / When OTHER SURGERY: What Where / When What Where / When FAMILY History : Place the family member letter after the check box for each family member who has / had the condition: Mother (M), Father (F), Brother (B), Sister (S), Maternal Grandmother (MGM), Maternal Grandfather (MGF), Paternal Grandmother (PGM), Paternal Grandfather (PGF): Allergies Cancer Type: Hearing deficiency Cancer Type.

3 CAD (Coronary Artery Disease) Alzheimer s / Dementia CVA (Stroke) Migraines Hypertension ADD/ADHD PVD (Peripheral Vascular Disease) Alcoholism Diabetes Depression Obesity Mental illness Asthma Osteoarthritis COPD Bleeding Disorders SOCIAL History : Tobacco Use? No Yes Former Age Started Age Stopped _____PPD // Do you consume alcohol? Yes No (13 years and older) Pediatric patients : Exposed to second hand smoke? Yes No Was this child Premature at Birth? Yes No Attends Child Care / Pre School? Yes No What is the reason for your visit Today ? TO BE COMPLETED BY THE NURSE CQM Questions: 1.

4 Does the Patient have Hi B/P: if yes, is it controlled with Meds (18-85) - Y / N 2. Breast CA Screening (40-69) - Y / N 3. Cervical CA Screen (50-75) - Y / N 4. Colorectal screen (50-70) - Y / N 5. Use of Asthma Med (5-64) - Y / N 6. Flu Shot (50 - >) - Y / N 7. Pneumonia Shot (65 - >) - Y / N 8. Does Patient have an Advanced Directive (65 - >)? - Y / N 9. Fall Risk: patients (65 - >) - Y / N