Patient History Form
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1ENT Patient History Form
Name:
Date of Birth:
Allergies/Intolerances
Date:
Patient's Preferred Name:
□
Medication
□ X-Ray Dye
Who referred you to us?
□
Pollen
□ Food
Occupation:
□
Soaps/Lotions
□ Environment
Special Interests:
□
Adhesives
□ None
Exposed to: □
Cigarette/cigar smoke
□ Animals/Pets
□Toxic Chemicals
□
Other:_______________________________
Substance Use:
□ None
List substances & reaction:
□ Tobacco _______ years. Daily amount ______ Quit years ago_______
____________________________________
□ Alcohol
daily amount ____________
____________________________________
Do you/have you had a drinking problem? □Yes □ No
____________________________________
□ Recrea onal drugs
type and re uency ____________
____________________________________
I desire help with substance abuse □Yes □ No
Please check yes or no next to each item.
Do you have or have you been treated for any of the following:
If an entire category/system does not apply,
None
□
check none next to that category
Yes No
Yes No
Head/Eyes
None
Skin
None
Teeth/Gum Disease
□
□
Trouble Swallowing
□
□
Asthma
□
□
Acid Re lux
□
□
Yes No
Yes No
Visual Changes
Bruising
□
□
T.B.
□
□
Blood clots
□
□
Light Sensitivity
Rashes
□
□
Emphysema
□
□
Bleeding Disorder
□
□
Blurred Vision
Sleep Apnea
□
□
HIV Concerns
□
□
Skin Lesions or
□
□
Double Vision
abnormalities
High Blood Pressure
□
□
Mental Disorder
□
□
Headaches
Heart Attack YR ____
□
□
Electrolyte Disorder
□
□
Gastrointestinal
None
Irregular Heart Beat
□
□
Hepatitis
□
□
ENT
None
Ulcers
□
□
Diabetes
□
□
Yes No
□
□
Stomach pain
Seizures
□
□
Yes No
Weight Gain
□
□
Sores in mouth or throat
Other Health Issues:
Face or neck lumps
Weight Loss
□
□
Dose
Since
Nose Bleeds
Nausea
□
□
Family History (blood relatives)
Medications
□
___________________
Vomiting
□
□
Heart Disease
□
Respiratory
None
___________________
Diarrhea
□
□
Cancer
□
___________________
Diabetes
Yes No
□
Psychiatric
None
___________________
Cough
Stroke
□
Dose
Since
Wheezing
Feelings of:
Bleeding Disorder
Non-Prescription Drugs:
Yes No
□
___________________________
Coughing up Blood
Depression
□
□
Anesthesia Problems
□
___________________
Snoring
Anxiety
□
□
Other
___________________
Cardiovascular
Endocrine
None
None
Current Doctors
Specialty
Yes No
Yes No
____________________________________________________________
Chest Pain
Heat or Cold
□
□
____________________________________________________________
Palpitations
Intolerance
____________________________________________________________
Musculoskeletal
Neurological
None
None
Surgeries
When?
____________________________________________________________
Yes No
Yes No
____________________________________________________________
Hand/Foot Swelling
□
□
Muscle Weakness
□
□
____________________________________________________________
□
□
Numbness/Tingling
□
□
Back or neck problems
____________________________________________________________
Dizziness/Instability □
□
Blood/Lymph
None
Light Headedness
□
□
Patient's Signature:___________________________________________
Yes No
Please stop here
Easy Bleeding
□
□
:________________________________________
Date:____________
Physician Signature
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Parent category: Medical