SEE ADDITIONAL DIRECTIONS ON BACK SIDE - ent …

1 Norman S. Druck, , W. Maack, , David Dahm, , Y. Park, , Lima, M. Mantia, FNP, BCPatricia Pitman, FNP, BCADULT & PEDIATRIC EAR, NOSE & THROAT HEAD & NECK SURGERY ALLERGYFACIAL PLASTIC SURGERY VOICE MEDICINE AUDIOLOGY HEARING SERVICES226 S. Woods Mill Road, Suite 37W Chesterfi eld, MO. 63017 (314)523-5300 Fax (314)434-319117000 Baxter Road, Suite 102 Chesterfi eld, MO. 63005 (314)523-5330 Fax (636)532-00355551 Winghaven Blvd Suite 230 O Fallon, MO. 63368 (636)695-4244 Fax (636)561-1180 Exchange: (314)388-6265 you for scheduling an appointment with ENT Associates, Inc. located at:St. Luke s Hospital 226 S. Woodsmill Rd, Suite 37 WChesterfi eld, MO 63017 Winghaven Medical Building 5551 Winghaven Blvd, Suite 230O Fallon, MO 63368 Synergi Facial Surgery 17000 Baxter Rd, Suite 102 Chesterfi eld, MO 63005!

2 SEE ADDITIONAL DIRECTIONS ON back SIDEP lease complete the enclosed forms and bring them with you for your appointment on_____, _____at _____ to bring your insurance card, co-payment and referral if needed from your primary doctor. If you have any CT scans, the report and offi ce notes, please bring those you have an HMO, you may also have the referral faxed to us listed Luke s Hospital226 S. Woodsmill Rd, Suite 37 WChesterfield, MO 63017 DIRECTIONS from St. Louis:Take Hwy 40 West to Exit 22 (MO-141/Woods Mill Rd). Merge onto North Outer 40 Road. Merge onto MO-141 North. Make a right turn onto Ladue Farm Rd (2nd Stoplight) entering the St. Luke s Hospital Complex.

3 Enter West parking garage (1st Bldg. on right). We are located on the yellow level of garage, which is the 3rd floor of the West Medical from St. Charles:Take Hwy 40 East to Exit 22 (MO-141/Woods Mill Rd). At stoplight, make a left onto MO-141/Woods Mill Rd. Make a right turn onto Ladue Farm Rd (2nd Stoplight) entering the St. Luke s Hospital Complex. Enter West parking garage (1st Bldg. on right). We are located on the yellow level of garage, which is the 3rd floor of the West Medical Building. *Valet Parking is available at front door of West Medical Medical Building 5551 Winghaven Blvd, Suite 230O Fallon, MO 63368 DIRECTIONS from Hwy 40/61:Take Hwy 40/61 West to Winghaven Blvd (MO-DD exit) and turn right.

4 Drive approximately 1/4 mile to 5551 Winghaven Blvd. (building on left-hand side ). DIRECTIONS from Hwy 70:Take Hwy 70 West to Bryan Road exit. Go South approximately 4 miles to 5551 Winghaven Blvd. (building on right-hand side ). DIRECTIONS from St. Charles or St. Peters:Take Hwy 94 or Hwy K South to Hwy 40/61 West to Winghaven Blvd. (MO-DD) and turn right. Drive approximately 1/4 mile to 5551 Winghaven Blvd. (building on left-hand side ).Synergi Facial Surgery17000 Baxter Rd, Suite 102 Chesterfield, MO 63005 DIRECTIONS from St. Louis:Take Hwy 40 West to Exit 17-Boone s Crossing. Make a left over the overpass. Make a left at the 2nd stoplight onto Chesterfield Airport Road.

5 Make a right at the 4th stoplight - about 1 mile to Baxter Road. We are the 2nd building on your right. Synergi DIRECTIONS from Saint Charles:Take Hwy 40 East to Exit 17-Boone s Crossing. Make a right and merge into the left lane. Turn left onto Chesterfield Airport Road. Make a right at the 4th stoplight - about 1 mile to Baxter Road. We are the 2nd building on your right. Synergi POS Reorder # 1120167 Account #Medical History QuestionnairePatient Name Age Date of Birth DatePrimary Care Physician Referring PhysicianToday s appointment with: Dr. Druck Dr. Maack Dr. Dahm Dr. Park Dr. Lima Dr. Marino Lisa MantiaNature of Visit: First visit, A consultation was requested by Doctor (Please list doctor s name) First visit, Referred by This is a follow-up visit Chief Complaint (Reason for today s visit) History of Present Illness: (Describe the signs/symptoms that you have, when they started, and how they have changed) Location (Where is the problem?)

6 Quality: (Dull, Throbbing, Sharp) Severity: (Mild, Moderate, Severe) Context: (Better, Worse, Chronic) Timing: (Daily, With activity, At night) Duration (How long does it last?) Associated signs & symptoms Modifying factors (What makes it better or worse?) Do you currently take ANY medications Yes No, if Yes, please list Name, Dosage and Frequency: Past Medical History (Have you been diagnosed with any of the following? Please check all that apply): Heart Trouble High Blood Pressure Diabetes Cancer Type Emphysema / COPD Asthma Kidney Disease Pneumonia Stroke / TIA Gastric Reflux Thyroid disorder Allergy Tuberculosis Sex.

7 Transmitted disease Genetic Disorder Sleep apnea Nervous / Psych disorder HIV Bleeding problems Autoimmune disorder Hepatitis, A B C Other: Past Surgical History: Tonsillectomy Adenoidectomy Nasal Sinus Surgery Ear Tubes Neck surgery Ear Surgery Heart Surgery Transplant Surgery Chemo or Radiation Therapy Surgeries, not listed above: Drug Allergies No Yes if yes, please list name of Drug Reaction:Latex Allergy No Yes*Please Continue On back side *A Division of POS Reorder # 1120169 Account # Social HistoryDo you drink Alcohol? Never Rarely No, I quit years ago. I was drinking drinks per day / week / month (circle one) for years.

8 Yes, I have drinks per day / week / month (circle one). List type of alcohol: Review of Current Symptoms: (Check any of the following that apply to you.) Family Medical History: (Do any family members have any of the medical problems listed below?) Check all that applyExample: Mother = M, Father = F, Maternal Grandmother = MGM, Maternal Grandfather = MGF, Paternal Grandmother = PGM, Paternal Grandfather = PGF, Brother = B, Sister = SVital Signs: Temperature Blood Pressure Pulse Height WeightPhysician Signature DateConstitutional Fever Weight Gain Night Sweats Fatigue Heart Trouble Diabetes Kidney/Liver Disease Bleeding Tendencies Gastric Reflux Hearing LossMusculoskeletal Foot Pain Muscle Weakness Joint PainEyes Vision change GlassesSkin RashENT Hearing Loss Vertigo Sore throat Hoarseness Nose BleedsRelationshipNeurology Numbness Headache Slurring SeizuresCardiovascular Chest Pain Foot/AnkleSwelling High Blood Pressure Cancer Asthma Stroke or TIA Nervous / Psychiatric Disorder OtherPsychiatry Confusion Anxiety DepressionRespiratory Shortness

9 Of Breath Wheezing Snoring Sleep ApneaEndocrine Heat ColdGastrointestinal Nausea Vomiting Diarrhea Heart Burn UlcersRelationshipHematology Swell/lymph BloodTransfusionGU Freq/urinate Pain/urinate Blood in urineAllergy Sneezing Itching Food CongestionPlease sign;Patient or Responsible Party Signature:Occupation Marital StatusEnvironmental Exposure: Dust Fumes Solvents NoiseDo you smoke tobacco? NO - If No: I have never smoked. I quit smoking years ago, I was smoking packs of cigarettes per day for years.

10 I quit using smokeless tobacco years ago. I was using smokeless tobacco for years. YES - If Yes: I smoke packs of cigarettes per day for years. I smoke cigars/pipe for years. I use snuff/chewing tobacco for to Second Hand Smoke currently or in the past? NO YES - If Yes: WHERE exposed? At Home At Work OtherPATIENT INFORMATIONLast Name: First: MI:Street Address: City: State: Zip:Home #: Cell #: Work #:Date of Birth: SS #: Marital Status: S M D W Sex:Employer Name and Address:Occupation: Employment Status: FT PT RT StudentPrimary Care Doctor: Referral Doctor (if different):Email Address:Emergency Contact Name and Number:Pharmacy Name, Address & Phone #:Language: English, Bosnian, French, German, Italian, Mandarin, Spanish, Vietnamese, OtherRace.