Patient Health History Form

Patient First Name (required)

Patient Middle Initial

Patient Last Name (required)

Social Security No.(required)

Patient's Date of Birth

Street Address

City

State

Zip Code

Sex
 Male Female

Home Phone

Work Phone

Cell Phone

Primary Physician

Referred by

Occupation

E-mail (required)

Marital Status
 Single Married Divorced Widowed Child

# of Children


Review of Systems - PLEASE CHECK EACH ITEM "Y" OR "N" AS IT RELATES TO YOUR CURRENT HEALTH


CONSTITUTIONAL
Weight Loss:  Y N
Weight Gain:  Y N
Fever:  Y N
Fatigue:  Y N
Appetite Change:  Y N

NOSE
Loss of Smell:  Y N
Nose Bleeds:  Y N
Nasal Pain:  Y N
Nasal Discharge:
Front:  Y N
Back:  Y N
Nasal Obstruction:  Y N
Nasal Congestion:  Y N
Snoring:  Y N
Post Nasal Drip:  Y N
Deviated Septum:  Y N
Runny Nose:  Y N
Nasal Sores/Lesions:  Y N
Headaches:  Y N
Sneezing:  Y N
None:  Y N

RESPIRATORY
Shortness of Breath:  Y N
Coughing Blood:  Y N
Wheezing:  Y N
Persistent Cough:  Y N
Frequent Infections:  Y N
None:  Y N

EYES
Glasses/Contacts:  Y N
Pain:  Y N
Double Vision:  Y N
Glaucoma:  Y N
Cataracts:  Y N
None:  Y N

CARDIOVASCULAR
Chest Pain:  Y N
Arm Pain:  Y N
Calf Pain:  Y N
Palpitations:  Y N
Swelling of Extremities:  Y N
Tightness/Pressure:  Y N
None:  Y N

EARS
Pain:  Y N
Hearing Loss:  Y N
Tinnitus:  Y N
Ear Drainage:  Y N
Itchy Ears:  Y N
Loss of Balance:  Y N
Vertigo:  Y N
Room Spins:  Y N
Ear Blockage/Obstruction:  Y N
Ear Infections:  Y N
Ear Lesions/Sores/Deformity:  Y N
None:  Y N

THROAT
Sore Throat:  Y N
Bad Tonsils/Tonsillitis:  Y N
Hoarseness:  Y N
Swallowing Problems:  Y N
Coughing:  Y N
Recurrent Infections:  Y N
Oral White Spots:  Y N
None:  Y N

GASTROINTESTINAL
Abdominal Pain:  Y N
Nausea/Vomiting:  Y N
Heartburn:  Y N
Rectal Bleeding:  Y N
Difficulty Swallowing:  Y N
Diarrhea:  Y N
Constipation:  Y N
None:  Y N

GENITOURINARY
Pain Urinating:  Y N
Burning:  Y N
Frequency:  Y N
Nighttime:  Y N
Blood in Urine:  Y N
Penile Discharge:  Y N
History of Sexually Transmitted Disease:  Y N
None:  Y N

PSYCHIATRIC
Anxiety:  Y N
Depression:  Y N
Mood Swings:  Y N
Insomnia:  Y N
None:  Y N

MUSCULOSKELETAL
Joint Pain/Swelling:  Y N
Stiffness:  Y N
Muscle Pain:  Y N
Back Pain:  Y N
None:  Y N

SKIN
Rash/Sores:  Y N
Lesions:  Y N
Itching:  Y N
Burning:  Y N
None:  Y N

ALLERGIC/IMMUNOLOGIC
Hay Fever:  Y N
Asthma:  Y N
Hives/Eczema:  Y N
None:  Y N

HEMATOLOGIC
Easy Bruising:  Y N
Gums Bleed Easily:  Y N
Prolonged Bleeding:  Y N
None:  Y N

ENDOCRINE
Loss of Hair:  Y N
Heat/Cold Intolerance:  Y N
Change in Nails:  Y N
Diabetes:  Y N
None:  Y N

NEUROLOGICAL
Seizures:  Y N
Headaches:  Y N
Numbness:  Y N
Memory Loss:  Y N
Loss of Consciousness:  Y N
None:  Y N


Past Patient History - PLEASE BE SPECIFIC AS TO REASON AND DATES


List ALL Operations/Hospitalizations with Reason & Date

List ALL Personal Illnesses/Injuries & Dates


Past Patient History - PLEASE CHECK EACH ITEM "Y" OR "N" AS IT RELATES TO YOUR PERSONAL HISTORY


NASAL PROBLEMS

Nasal congestion, stuffiness, blockage:  Y N
Frequent sneezing:  Y N
Decreased ability to smell:  Y N
Drainage down the back of throat:  Y N
Sleep disturbance from nasal problems:  Y N

SINUS PROBLEMS

Sinus pressure:  Y N
Sinus headaches:  Y N
Sinus infections:  Y N

EAR PROBLEMS

Popping of ears:  Y N
Ringing of ears:  Y N
Pressure, discomfort, congestion:  Y N
Changes in hearing:  Y N

THROAT PROBLEMS

Frequent need to clear throat:  Y N
Persistent sore throat:  Y N
Hoarseness:  Y N

EYE PROBLEMS

Itching, burning:  Y N
Excessive tears:  Y N
Redness/swelling:  Y N

ALLERGIES

Have you ever had allergy testing?  Y N
Did you receive allergy shots?  Y N
Listing date of testing:  Y N

List allergies discovered:

ADDITIONAL CONDITIONS

Have you had nasal polyps?  Y N
Sinus surgery:  Y N
Pneumonia:  Y N
Anemia:  Y N
Cancer, list type:  Y N
Blood Clots:  Y N
Bleeding problems:  Y N


Pact Family History - PLEASE COMPLETE THE FOLLOWING TABLE


  Age if Alive Health Problems Age at Death Cause of Death
Mother:
Father:
Siblings
Grandparents:

Please List All Current Prescription Medications or Over the Counter Medications and Dosages


List the Medication Name, Dose, and the Number of Times Taken Per Day for each medication in the box below.

Are there any medications which you stopped taking in the past month?  Y N

Are you currently taking Asprin, Advil or Motrin?  Y N How often?

Are you allergic to any medication?  Y N

List ALL Drug Allergies & Describe Your Allergic Reaction to Each

List ALL Environmental and Food Allergies & Describe Your Allergic Reaction to Each


Social History - Patient PLEASE ANSWER THE FOLLOWING QUESTIONS


Have you ever smoked?  Y N

If yes: # packs/day

# years smoked

Are you still smoking?  Y N

If you have stopped smoking, when did you quit?

Do you drink alcohol?  Y N If yes, please list type and quantity:

Are you use recreational drugs?  Y N What type

Do you exercise?  Y N Describe

Send my history form to: