Patient Questionnaire Page 2
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3JOHNS HOPKINS OUTPATIENT CENTER
PATIENT STAMP HERE
DEPARTMENT OF OTOLARYNGOLOGY-
HEAD AND NECK SURGERY
PATIENT QUESTIONNAIRE - PAGE 2 OF 2
SOCIAL HISTORY:
Occupation_______________________________________
Marital status:
Single
Married
Divorced
How many children do you have?______________________
Have you ever used tobacco?
Cigarettes
Cigar
Pipe
Chew
Never used tobacco
How much, and for how long have you used tobacco?________________________ per day for _______________years
How much alcohol do you drink each day?______________________________________________________________
How much caffeine do you drink per day?_______________________________________________________________
List any street drugs you currently or have ever used:______________________________________________________
REVIEW OF SYSTEMS (Check all symptoms you have had either now or in the past):
CONSTITUTIONAL:
Weight loss ________ pounds in the past ________ weeks
Fever, chills
Weakness or fatigue
EYES:
EARS, NOSE, THROAT:
Double vision
Hearing loss
Nose bleeds
Swallowing pain
Loss of vision
Ringing in ears
Nose drainage
Voice change
Eye pain
Dizziness
Nasal congestion
Snoring
Eye drainage
Ear pain
Facial pain
Hoarseness
Dry eyes
Ear drainage
Headaches
Poor sleep
Tooth aches
Sore mouth/throat
Neck pain or swelling
CARDIOVASCULAR/PULMONARY:
Chest pain
Heart attack
Irregular heartbeat
Bronchitis
Poor circulation
Leg pain during walking
Frequent cough
Coughing up blood
Shortness of breath
Asthma or wheezing
GASTROINTESTINAL:
Stomach ulcers
Nausea/vomiting
Diarrhea
Frequent antacid use
Heartburn
Trouble swallowing
Abdominal pain
Blood in stool
GENITOURINARY:
Blood in urine
Pain during urination
Difficulty making urine
MUSCULOSKELETAL:
Neck or back pain
Muscle aches
Arthritis
NEUROLOGICAL:
Stroke
Ministroke or TIA
Head trauma
Seizure
Facial paralysis
Paralysis of arm or leg
Confusion
Memory loss
Numbness in face, arms or legs
Temporary loss of vision or speech control
SKIN:
Skin cancers
Allergy to tape, iodine or latex
PSYCHIATRIC:
Depression
Schizophrenia
Anxiety or panic attacks
Hallucinations
Other psychiatric disorder (please list):______________________________________
INFECTIOUS DISEASE:
Hepatitis
HIV/AIDS
Mononucleosis
Shingles
Syphilis
TB
Any sexually transmitted disease_________________
I have personally reviewed this history and review of systems:
___________________________________________________
___________________________________
Attending Physician Signature
Date
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