Form #10ll - Patient History Form
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2Southern Illinois Otolaryngology
Larry C. Dobbs, M.D., F.A.C.S.
2900 Frank Scott Parkway West
Suite 930 • Belleville, IL 62223
Patient History Form
Patient Name:______________________________________________________
DOB:____/____/____
Past Medical History
Allergies to Medication:_____________________________________________________________________
Current Medication
1___________________ 4___________________ 7___________________
Prescription Medication:
2___________________ 5___________________ 8___________________
3___________________ 6___________________ 9___________________
1___________________ 2___________________ 3___________________
Over-the-Counter Medications:
Check any illness or condition you have had:
r
None of these
r
Diabetes
r
Ulcer
r
Cancer
r
Hepatitis
Kidney disease
Bleeding Problems
Tuberculosis(TB)
Seizures/Epilepsy
r
r
r
r
High blood pressure
Heart disease
Stroke/TIA
Nervous illness
r
r
r
r
Allergies
Urinary Incontinence
Latex Allergies
Other:_____________
r
r
r
r
Hospitalizations: (List problem(s) and year, not including surgeries) __________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Surgeries: (List operations and the year performed) ______________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Preventive Care:
(check box if ever had and list year performed)
Influenza Vaccine: ________
Pneumonia Vaccine: ________
BMI Measured: ________
r
r
r
Colonoscopy: ________
Mammogram: ________
Osteoporosis Bone Scan: ________
r
r
r
Social History
Occupation: ____________________________________________________________________________
Employed full time
Employed part time
Retired
Disabled
r
r
r
r
Number of people in household:
Adults_________ Children_________
Do you smoke now?
r
Yes
r
No
If quit, date quite: ____/____/____
If you smoke now, or used to, for how many years? _____
About how many cigarettes do you or did you smoke each day? _____
Do/did you use any of the following tobacco products?
Cigar
Pipe
Chew
None
r
r
r
r
Do you drink alcohol now?
r
Yes
r
No
If no, did you ever drink alcohol?
r
Yes
r
No
When you drink or used to drink, how many beers/drinks per day? _____
If you used to drink and quit, how long since you stopped? _____
Family History
Serious Illnesses:
____________________________________________________________________
Cancer:
____________________________________________________________________
Other:
____________________________________________________________________
PLEASE TURN TO PAGE 2
Form #10LL - 1/13
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