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Patient History, Review of Systems Form

OTOLARYNGOLOGY CLINICAL HISTORY FORM
First Name:	Middle:	Last:

SSN:	Date of Birth:	Age/Gender:	/
Address:	City:	State/Zip:	/
Home Phone:	Work Phone:	Cell Phone:
Primary Physician:	Referred by:
Occupation:	Marital Status:	# of Children:

Review Of Systems - PLEASE CHECK EACH ITEM "Y" OR "N" AS IT RELATES TO YOUR CURRENT HEALTH
CONSTITUTIONAL		NOSE		RESPIRATORY
Weight Loss:	Y N	Loss of Smell:	Y N	Shortness of Breath:	Y N
Weight Gain:	Y N	Nose Bleeds:	Y N	Coughing Blood:	Y N
Fever:	Y N	Nasal Pain:	Y N	Wheezing:	Y N
Fatigue:	Y N	Nasal Discharge		Persistent Cough:	Y N
Appetite Change:	Y N	Front:	Y N	Frequent Infections:	Y N
		Back:	Y N	None:	Y N
EYES		Nasal Obstruction:	Y N
Glasses/Contacts:	Y N	Nasal Congestion:	Y N	CARDIOVASCULAR
Pain:	Y N	Snoring:	Y N	Chest Pain:	Y N
Double Vision:	Y N	Post Nasal Drip:	Y N	Arm Pain:	Y N
Glaucoma:	Y N	Deviated Septum:	Y N	Calf Pain:	Y N
Cataracts:	Y N	Runny Nose:	Y N	Palpitations:	Y N
None:	Y N	Nasal Sores/Lesions:	Y N	Swelling of Extremities:	Y N
		Headaches:	Y N	Tightness/Pressure:	Y N
EARS		Sneezing:	Y N	None:	Y N
Pain:	Y N	None:	Y N
Hearing Loss:	Y N			GASTROINTESTINAL
Tinnitus:	Y N	THROAT		Abdominal Pain:	Y N
Ear Drainage:	Y N	Sore Throat:	Y N	Nausea/Vomiting:	Y N
Itchy Ears:	Y N	Bad Tonsils/Tonsillitis:	Y N	Heartburn:	Y N
Loss of Balance:	Y N	Hoarseness:	Y N	Rectal Bleeding:	Y N
Vertigo:	Y N	Swallowing Problems:	Y N	Difficulty Swallowing:	Y N
Room Spins:	Y N	Coughing:	Y N	Diarrhea:	Y N
Ear Blockage/ Obstruction:	Y N	Recurrent Infections:	Y N	Constipation:	Y N
Ear Infections:	Y N	Oral White Spots:	Y N	None:	Y N
Ear Lesions/Sores/ Deformity:	Y N	None:	Y N
None:	Y N

GENITOURINARY		PSYCHIATRIC		MUSCULOSKELETAL
Pain Urinating:	Y N	Anxiety:	Y N	Joint Pain/Swelling:	Y N
Burning:	Y N	Depression:	Y N	Stiffness:	Y N
Frequency:	Y N	Mood Swings:	Y N	Muscle Pain:	Y N
Nighttime:	Y N	Insomnia:	Y N	Back Pain:	Y N
Blood in Urine:	Y N	None:	Y N	None:	Y N
Penile Discharge:	Y N
History of Sexually Transmitted Disease	Y N	ALLERGIC/ IMMUNOLOGIC		HEMATOLOGIC
None:	Y N	Hay Fever:	Y N	Easy Bruising:	Y N
		Asthma:	Y N	Gums Bleed Easily:	Y N
SKIN		Hives/Eczema:	Y N	Prolonged Bleeding:	Y N
Rash/Sores:	Y N	None:	Y N	None:	Y N
Lesions:	Y N
Itching:	Y N	ENDOCRINE
Burning:	Y N	Loss of Hair:	Y N
None:	Y N	Heat/Cold Intolerance:	Y N
		Change in Nails:	Y N
NEUROLOGICAL		Diabetes:	Y N
Seizures:	Y N	None:	Y N
Headaches:	Y N
Numbness:	Y N
Memory Loss:	Y N
Loss of Consciousness:	Y N
None:	Y N

Past Patient History - PLEASE BE SPECIFIC AS TO REASON AND DATES
List ALL Operations/Hospitalizations with Reason & Date	Please List ALL Personal Illnesses/Injuries & Dates

Past Patient History - PLEASE CHECK EACH ITEM "Y" OR "N" AS IT RELATES TO YOUR PERSONAL HISTORY
NASAL PROBLEMS		EYE PROBLEMS
Nasal congestion, stuffiness, blockage	Y N	Itching, burning	Y N
Frequent sneezing	Y N	Excessive tears	Y N
Decreased ability to smell	Y N	Redness/swelling	Y N
Drainage down the back of throat	Y N	ALLERGIES
Sleep disturbance from nasal problems	Y N	Have you ever had allergy testing	Y N
SINUS PROBLEMS		Did you receive allergy shots	Y N
Sinus pressure	Y N	List date of testing
Sinus headaches	Y N	List allergies discovered
Sinus infections	Y N
EAR PROBLEMS		ADDITIONAL CONDITIONS
Popping of ears	Y N	Have you had nasal polyps	Y N
Ringing of ears	Y N	Sinus Surgery	Y N
Pressure, discomfort, congestion	Y N	Pneumonia	Y N
Changes in hearing	Y N	Anemia	Y N
THROAT PROBLEMS		Cancer, list type
Frequent need to clear throat	Y N	Blood clots	Y N
Persistent sore throat	Y N	Bleeding problems	Y N
Hoarseness	Y N

Pact Family History - PLEASE COMPLETE THE FOLLOWING TABLE
	Age if Alive	Health Problems	Age at Death	Cause of Death
Mother:
Father:
Siblings:
Grandparents:

Please List All Current Prescription Medications or Over the Counter Medications and Dosages
List the Medication Name, Dose, and the Number of Times Taken Per Day for each medication in the box to the right.
Are there any medications which you stopped taking in the past month? Y N If you answered "Y", which medications have your stopped? Are you currently taking Aspirin, Advil or Motrin? Y N How often? Are you allergic to any medication? Y N

List ALL Drug Allergies & Describe Your Allergic Reaction to Each

List All Environmental and Food Allergies & Describe Your Allergic Reactions to Each

Social History - Patient PLEASE ANSWER THE FOLLOWING QUESTIONS
Y N	Have you ever smoked? If yes: # packs/day # years smoked
Y N	Are you still smoking? If you have stopped smoking, when did you quit?
Y N	Do you drink alcohol? If yes, please list type and quantity:
Y N	Do you use recreational drugs? What type
Y N	Do you exercise? Describe
Send my history form to: