West Michigan Ear, Nose And Throat - Patient Health History Form Page 2
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1
2WEST
M ICHIGAN
E AR,
N OSE
&
T HROAT
P ATIENT
H EALTH
H ISTORY
F ORM
-‐
Patient
N ame:_____________________________________________________
D ate
o f
B irth_________________________
REVIEW
O F
S YSTEMS
Are
Y OU
c urrently
h aving,
o r
e ver
h ad
p roblems
w ith
( check
a ll
t hat
a pply):
Constitutional
____
C hronic
C ough
____
J oint
P ain
____
W eight
G ain
____
C oughing
B lood
____
J oint
S welling
____
W eight
L oss
____
A sthma
____
A rthritis
____
N ight
S weats
____
T uberculosis
( TB)
____
I nsomnia
____
P neumonia
Neurologic
____
F ever
____
T rouble
B reathing
a t
N ight
____
F ainting
S pell/Blacking
O ut
____
S noring
____
D isorientation
Allergic/Immunologic
____
S hortness
o f
B reath
____
N umbness
____
S neezing
____
B ronchitis
____
W eakness
____
I tching
e yes/nose
____
W heezing
____
S peech
D ifficulty
____
I tchy
T hroat
____
L oss
o f
C oordination
____
S kin
R ash
Cardiovascular
____
F acial
W eakness
____
H IV
____
C hest
P ain
o r
A ngina
____
S troke
____
F ood
A llergy
_ _______
____
H eart
T rouble
____
H eadache
____
N asal
A llergy
____
R heumatic
F ever
____
D ouble
o r
B lurred
V ision
____
H eart
M urmur
Eyes
____
H igh
C holesterol
Psychiatric
____
W atery
E yes
____
H igh
B lood
P ressure
____
D epression
____
D ouble
V ision
____
I rregular
p ulse
____
A nxiety
____
V isual
L oss
____
L eg
S welling
____
O ther
P sych
D isorder
____
E ye
I njuries
____
P alpitations
Endocrine
Ear,
N ose,
T hroat
&
M outh
Gastrointestinal
____
D iabetes
____
W ears
H earing
A ids
____
I ndigestion
o r
h eartburn
____
T hyroid
P roblems
____
H earing
L oss
____
F ood
I ntolerance
____
E xcessive
T hirst
____
R inging
I n
t he
E ars
____
U lcer
____
U rinary
F requency
____
E ar
P ain
____
H epatitis
____
O ther
H ormone
I ssues
____
E ar
I nfection
____
J aundice
____
E ar
I tching
____
B lood
i n
S tool
Hematologic
____
B alance
P roblems
____
B lack,
T arry
S tool
____
A nemia
____
N osebleeds
____
N ausea
____
P ersistent
S wollen
G lands
____
I nability
t o
s mell
____
V omiting
____
E asy
B leeding/bruising
____
N asal
C ongestion
____
A bdominal
P ain
____
N asal
D rainage
____
S inus
P roblems
Genitourinary
____
N asal
I tching
____
B ladder
T rouble
____
D ry
M outh
____
P rostate
D isease
____
S ore
T hroat
____
K idney
D isease
____
S ore
T ongue
____
P ainful
U rination
____
T rouble
s wallowing
____
B lood
i n
U rine
____
H oarseness
____
K idney
S tones
Musculoskeletal
Respiratory
____
M uscle
W eakness
Rev:
5 /2015
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