New Patient Information Form
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1
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3New Patient Information Form
Name :
Birth Date :
/
/
Page 1
1. Medical History
2. Specialists
List any other doctors that you see: _______________________
DO YOU HAVE OR HAVE YOU EVER HAD (
please check box)
____________________________________________________
No Known Medical Conditions
____________________________________________________
Anesthesia Problems (specify ________________________)
____________________________________________________
Bleeding Disorder (specify __________________________)
____________________________________________________
Hearing Loss
Ear Infections
3. Surgical History
Ruptured Ear Drum
No Surgical History
Sinusitis
Ear Tubes: when______
Septoplasty: when______
Facial Trauma
Tonsils: when_____
Sinus Surgery: when______
Tonsillitis (chronic)
Adenoids: when_____
Heart Disease
Thyroid (partial, total): when______
Hypertension
Cardiac Stent: when________
High Cholesterol
Coronary Artery Bypass: x ______, when _______
Arrhythmia
Joint Replacement: (specify ____________): when________
Other Cardiac Disorder (specify_______________________)
Asthma
Please list any additional operations (and dates) that you have
Sleep / Snoring Problems (specify_____________________)
had. ________________________________________________
Other Lung Disease (specify ________________________)
____________________________________________________
Stomach Ulcers / Colitis
____________________________________________________
GERD (Reflux)
Other Stomach Disorder (specify______________________)
4. Family History
Acute Renal Failure
No Known Medical Conditions
Kidney Stones
Anesthesia Problems (specify ________________________)
Other Renal Disease (specify_________________________)
Bleeding Disorder (specify __________________________)
Musculoskeletal Disorder (specify_____________________)
Hearing Loss: Relationship:_________________
Diabetes (specify_________________ controlled ?_______)
Sinusitis
Osteoarthritis
Heart Disease
Osteoporosis
Hypertension
Thyroid Disease (specify____________________________ )
High Cholesterol
Other Endocrine Disorder (specify ____________________ )
Other Cardiac Disorder (specify_______________________)
Headache /Migraine
Asthma
Seizures (specify___________________________________)
Other Lung Disease (specify ________________________)
Stroke/TIAs (specify________________________________)
GERD (Reflux)
Other Neurologic Disorder (specify ___________________ )
Other Stomach Disorder (specify______________________)
Anemia (Iron Deficiency, Hemolytic or Pernicious)
Renal Failure
Environmental Allergies
Other Renal Disease (specify_________________________)
Chicken Pox
Rheumatoid Arthritis
Immune Deficiency
Lupus
Other Allergy (specify______________________________ )
Musculoskeletal Disorder (specify_____________________)
History of Cancer: Type: ____________________________
Thyroid Disease (specify____________________________ )
Diagnosed:___________ Treatment:______________
Other Endocrine Disorder (specify ____________________ )
Psychiatric Disorder (specify_________________________)
Headache /Migraine
Do you have any other disease or condition that you think the
Seizures (specify___________________________________)
doctor should know about?___________________________
Stroke/TIAs (specify________________________________)
_________________________________________________
Vertigo
Other Neurologic Disorder (specify ____________________)
For Women Only
Allergy/Immune/Skin (specify ________________________)
Are you pregnant, or is there any chance that you might be
Cancer : Type:_________ Relationship:_________________
pregnant?
Type:_________ Relationship:_________________
Are you nursing?
Psychiatric Disorder (specify_________________________)
Patrick J. Chiles, M.D. Eric K. Fung, M.D. Amy L. Reynders, M.D. Rebecca Sleeper, R.N.N.P
3906 E. Genesee Street – Syracuse, NY 13214-1934
Phone-(315) 251-1093
Fax- (315) 251- 1571
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